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Benign Prostatic Hyperplasia
J. de la Rosette, G. Alivizatos, S. Madersbacher, C. Rioja Sanz, J. Nordling, M. Emberton, S. Gravas, M.C. Michel, M. Oelke,
© European Association of Urology 2006
TABLE OF CONTENTS
1. BACKGROUND 1.1 Prevalence 1.2 Is BPH a progressive disorder? 1.2.1 Indicators of progression 1.2.2 Conclusions 1.2.3 References RISK FACTORS 2.1 For developing the disease 2.2 For surgical treatment 2.3 References ASSESSMENT 3.1 Symptom scores 3.1.1 International Prostate Symptom Score (I-PPS) 3.1.2 Quality-of-life assessment 3.1.3 Symptom score as decision tool for treatment 3.1.4 Symptom score as outcome predictor 3.1.5 Conclusions 3.1.6 Recommendations 3.1.7 References 3.2 Prostate specific antigen (PSA) measurement 3.2.1 Factors influencing the serum levels of PSA 3.2.2 PSA and prediction of prostatic volume 3.2.3 PSA and probability of having prostate cancer 3.2.4 PSA and prediction of BPH-related outcomes 3.2.5 Conclusions 3.2.6 Recommendation 3.2.7 References 3.3 Creatinine measurement 3.3.1 Conclusions 3.3.2 References 3.4 Urinalysis 3.4.1 Recommendation 3.5 Digital rectal examination (DRE) 3.5.1 DRE and cancer detection 3.5.2 DRE and prostate size evaluation 3.5.3 Conclusions and recommendations 3.5.4 References 3.6 Imaging of the urinary tract 3.6.1 Upper urinary tract 3.6.2 Lower urinary tract 3.6.3 Urethra 3.6.4 Prostate 3.6.5 References 3.7 Voiding charts (diaries) 3.7.1 Conclusions 3.7.2 References 3.8 Uroflowmetry 3.8.1 References 3.9 Post-void residual volume (PVR) 3.10 Urodynamic studies 3.10.1 Outcome 3.10.2 Conclusions 3.10.3 References 3.11 Endoscopy 3.11.1 LUTS caused by bladder outlet obstruction 3.11.2 Morbidity of urethrocystoscopy
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3.11.3 Relationship between trabeculation and peak flow rate 3.11.4 Relationship between trabeculation and symptoms 3.11.5 Relationship between trabeculation and prostate size 3.11.6 Relationship between trabeculation and obstruction 3.11.7 Bladder diverticula and obstruction 3.11.8 Bladder stones and obstruction 3.11.9 Intravesical pathology 3.11.10 Conclusions 3.11.11 References Recommendations for assessment
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TREATMENT 4.1 Watchful waiting (WW) 4.1.1 Patient selection 4.1.2 Education, reassurance and periodic monitoring 4.1.3 Lifestyle advice 4.1.4 Conclusions 4.1.5 References 4.2 Medical treatment 4.2.1 5-Alpha reductase inhibitors 184.108.40.206 Finasteride (type 2, 5-Alpha reductase inhibitor) 220.127.116.11.1 Efficacy and clinical endpoints 18.104.22.168.2 Haematuria and finasteride 22.214.171.124.3 Side-effects 126.96.36.199.4 Effect on PSA 188.8.131.52 Dutasteride 184.108.40.206 Combination therapy 220.127.116.11 Conclusions 18.104.22.168 References 4.2.2 Alpha-blockers 22.214.171.124 Uroselectivity 126.96.36.199 Mechanism of action 188.8.131.52 Pharmacokinetics 184.108.40.206 Assessment 220.127.116.11 Clinical efficacy 18.104.22.168 Durability 22.214.171.124 Adverse effects 126.96.36.199 Acute urinary retention 188.8.131.52 Conclusions 184.108.40.206 References 4.2.3 Phytotherapeutic agents 220.127.116.11 Conclusions 18.104.22.168 References 4.3 Surgical management 4.3.1 Indications for surgery 4.3.2 Choice of surgical technique 4.3.3 Perioperative antibiotics 4.3.4 Treatment outcome 4.3.5 Complications 4.3.6 Long-term outcome 4.3.7 Conclusions and recommendations 4.3.8 References 4.4 Lasers 4.4.1 Laser types 4.4.2 Right-angle fibres 4.4.3 Interstitial Laser Coagulation (ILC) 4.4.4 Holmium laser resection of the prostate (HoLRP) 4.4.5 Conclusions 4.4.6 References 4.5 Transrectal high-intensity focused ultrasound (HIFU)
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4.5.1 Assessment 4.5.2 Procedure 4.5.3 Morbidity/complications 4.5.4 Outcome 4.5.5 Urodynamics 4.5.6 Quality of life and sexual function 4.5.7 Durability 4.5.8 Patient selection 4.5.9 Conclusions 4.5.10 References Transurethral needle ablation (TUNA®) 4.6.1 Assessment 4.6.2 Procedure 4.6.3 Morbidity/complications 4.6.4 Outcome 4.6.5 Randomized clinical trials 4.6.6 Impact on bladder outflow obstruction 4.6.7 Durability 4.6.8 Patient selection 4.6.9 Conclusions 4.6.10 References Transurethral microwave therapy (TUMT) 4.7.1 Assessment 4.7.2 Procedure 4.7.3 The microwave thermotherapy principle 4.7.4 Morbidity 4.7.5 High-intensity-dose-protocol 4.7.6 Prostatic temperature feedback treatment 4.7.7 Durability 4.7.8 Patient selection 4.7.9 Conclusions 4.7.10 References Recommendations for treatment
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FOLLOW-UP 5.1 Watchful waiting 5.2 Alpha-blocker therapy 5.3 5-Alpha-reductase inhibitors 5.4 Surgical management 5.5 Alternative therapies ABBREVIATIONS USED IN THE TEXT
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Benign prostatic hyperplasia (BPH) is a condition intimately related to ageing (1). Although it is not lifethreatening, its clinical manifestation as lower urinary tract symptoms (LUTS) reduces the patient’s quality of life (2). Troublesome LUTS can occur in up to 30% of men older than 65 years (3).
Although many epidemiological clinical studies have been conducted worldwide over the last 20 years, the prevalence of clinical BPH remains difficult to determine. A standardized clinical definition of BPH is lacking, which makes it intrinsically difficult to perform adequate epidemiological studies. Among the published epidemiological studies, some include probability samples from an entire country, while others represent agestratified random samples or enrol participants from general practice, hospital populations or responders to selective screening programmes. There is also a lack of homogeneity among these studies in the way in which BPH is assessed, with different questionnaires and methods of administration. Barry et al. have provided the histological prevalence of BPH, based on a review of five studies relating age to histological findings in human male prostate glands (4). Histological BPH was not found in men under the age of 30 years but its incidence rose with age, reaching a peak in the ninth decade. At that age, BPH was found in 88% of histological samples (4). A palpable enlargement of the prostate has been found in up to 20% of males in their 60s and in 43% in their 80s (5); however, prostate enlargement is not always related to clinical symptoms (2). Clinical BPH is a highly prevalent disease. By the age of 60 years, nearly 60% of the cohort of the Baltimore Longitudinal Study of Aging had some degree of clinical BPH (6). In the USA, results of the Olmstead County survey, in a sample of unselected Caucasian men aged 40-79 years, showed that moderate-to-severe symptoms can occur among 13% of men aged 40-49 years and among 28% of those older than 70 years (1). In Canada, 23% of the cohort studied presented with moderate-to-severe symptoms (7). The findings for prevalence of LUTS in Europe are similar to those in the USA. In Scotland and in the area of Maastricht, the Netherlands, the prevalence of symptoms increased from 14% of men in their 40s to 43% in their 60s (8,9). Depending on the sample, the prevalence of moderate-to-severe symptoms varies from 14% in France to 30% in the Netherlands (10,11). The proportion of men with moderate-to-severe symptoms doubles with each decade of life (10). Preliminary results of one of the most recent European epidemiological studies on the prevalence of LUTS show that approximately 30% of German males aged 50-80 years present with moderateto-severe symptoms according to the International Prostate Symptom Score (i.e. I-PSS > 7) (12). A multicentre study performed in different countries in Asia showed that the age-specific percentages of men with moderate-to-severe symptoms were higher than those in America (13,14). The prevalence increases from 18% for men in their 40s to 56% for those in their 70s (13). Curiously, the average weight of Japanese glands seemed to be smaller than those of their American counterparts (15). Despite methodological differences, some conclusions can be drawn from the studies mentioned above: • Mild urinary symptoms are very common among men aged 50 years and older. • Mild symptoms are associated with little bother, while moderate and severe symptoms are associated with increasingly higher levels of inconvenience and interference with living activities (16). • The same symptoms can cause different troublesome and daily living interference (17). • The correlation between symptoms, prostate size and urinary flow rate is relatively low (18). It must be stressed that there is still a need for an epidemiological definition of BPH and its true incidence has yet to be determined (19).
Is BPH a progressive disorder?
As it is almost impossible to obtain agreement on what it is that defines a man with LUTS/BPH, it seems logical to say that progression cannot be defined in terms of a transition from non-cases to cases. Instead, progression must be measured by documenting deterioration in any number of physiological variables that we associate with the LUTS/BPH syndrome. Traditionally these have included the following: • decrease in maximum flow rate • increase in residual volume • increase in prostate size • deterioration (increase) in symptom score. In addition, definable events, such as the occurrence of acute urinary retention or prostate surgery, have been used. Less commonly, changes in urodynamic variables and deterioration in disease-specific quality of life have been advocated. Considerable interest currently rests with PSA. It appears to be as good a predictor of progression as any of the variables mentioned above.
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0 34. but current data are not as convincing as those for age. PSA (PLESS) and prostate volume (combined 2-year placebo analysis). or none. Table 1: Strength of evidence for specific parameters as indicators of progression of benign prostatic hyperplasia (BPH) Parameter IPSS BII QoL DRE TRUS MRI Qmax Histology AUR Surgery Crossover/treatment Community.2%c 0.3 11. LUTS = lower urinary tract symptoms. N = no evidence. W = weak. QoL = quality of life. BII = BPH Impact Index. they are very rare and therefore could not be evaluated accurately in community-based and clinical studies.3 in 4 yearsb NR -2% per year NR +0. I-PSS = International Prostate Symptom Score.5-3.3 10. PSA level and prostate volume. TRUS = transrectal ultrasonography. The evidence for the progression of BPH has been summarised previously (22). These parameters could potentially be used in decisions about treatment management. The actual rates of progression of the individual parameters as determined from the papers reviewed is shown in Table 2. have been associated with progression of BPH. Although these are important. such as renal impairment and bladder dysfunction. The strength of evidence for individual parameters as indicators of progression is summarised in Table 1 and is categorised as strong. N/A = not available.1 Indicators of progression The strongest evidence to support progression comes from the Olmsted County (20) community-based study and the PLESS placebo group (21).9%d NR 10% over 4 years NR 10-39%e 2-year studies (30-34) North AmeNR NR rican (35) a Men with moderate to severe symptoms.18 per year NR -1. DRE = digital rectal examination.2.9% per year NR +14% in 4 years NR NR Acute urinary retentiona (Incidence/1000 person years) > 70 40-49 years years 3.7 3.based studies S S N N S N S N/A S S S Clinical trials N/W* N/N W/S* N S S/S* W/S* N/A S/S* W/S* N LUTS BPE BOO BPH Miscellaneous *Conditional risk factors: age and prostate-specific antigen (PSA). Table 2: Rates of progression of individual parameters in BPH Study Rate of progression LUTS Flow rate (points) Prostate size Olmsted (23-27) Health Professional (28) PLESS (29) 0. 6 UPDATE MARCH 2004 . BOO = bladder outlet obstruction. The same strategy could be applied to patients who are at increased risk of progression based on recognised risk factors. Several other complications.9 NR NR 7% over 4 years 1. such as symptom severity and decreased urinary flow rate. S = strong. MRI = magnetic resonance imaging.3 Surgerya (Incidence/1000 person years) > 70 40-49 years years 0. Qmax = maximum flow rate.2 mL/s in 4 yearsb NR 1. Risk factors for progression were found to be age (Olmsted County). AUR = acute urinary retention. weak.6-4. BPE = benign prostatic enlargement.1. Patients who show signs of more pronounced disease progression could be targeted for preventative strategies. Other baseline risk factors can be identified.
nlm. Bosch JL.fcgi?cmd=Retrieve&db=PubMed&list_uids=1714529& dopt=Abstract Wolfs GGMC.fcgi?cmd=Retrieve&db=PubMed&list_uids=9393291& dopt=Abstract Chapple CR. Coast J. http://www. http://www. Nissenkorn I. 7.2. Teillac P. Knottnerus JA. Peters TJ.nih.nih. Jacobsen SJ.nlm.e.nih. 3.338:469-471.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7532230& dopt=Abstract 2. Kay HE. Lancet 1991.ncbi. International Continence Society .nlm. The prevalence of prostatism: a population based survey of urinary symptoms.ncbi.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=7530115& dopt=Abstract Garraway WM. Harvard BM.734 elderly men.ncbi. 9. d According to baseline prostate-specific antigen (PSA) level.35(Suppl):4-8. 8.nih.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=7933185& dopt=Abstract Sagnier PP.Flow rate and LUTS responded to placebo treatment by showing an initial improvement. 10. NR = not reported. Pickett SN.80:712-721.gov/entrez/query.ncbi. Girman CJ. It might be appropriate to identify these patients at risk of progression and initiate early preventative treatment. Nickel JC. Guess HA.nih. Emery JM. 4. Botto H. Ewing LL. Lieber MM. Oesterling JE.15:669-673.gov/entrez/query.99:639-645. PSA level and prostate volume.74:542-550. http://www. The incidence of benign prostatic hypertrophy. age. b 1. c According to baseline prostate volume.ncbi. http://www. There are limited published data on longitudinal studies and the key pieces of evidence that support this notion are the Olmsted County and PLESS studies.2 CONCLUSIONS Based on published data on consequences and complications of the disease. Abrama P. http://www.nlm. Richard F. Coffey DS. Walsh PC. Guess HA. BPH can be considered a progressive disease. High prevalence of benign prostatic hypertrophy in the community. Matos-Ferreira A. Schick E.gov/entrez/query.gov/entrez/query. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=6206240& dopt=Abstract Lytton B. Using the ICSQoL to measure the impact of lower urinary tract symptoms on quality of life: evidence from the ICS-‘BPH’ study. http://www. Collins GN.ncbi.nlm. Boyle P. 1. Eur Urol 1999.gov/entrez/query. Barbalias G. J Urol 1993.fcgi?cmd=Retrieve&db=PubMed&list_uids=4171950& dopt=Abstract Arrighi HM. Lee RJ. 5. Nordling J. the Baltimore Longitudinal Study of Aging. Silva MM.150:85-89. The development of human benign prostatic hyperplasia with age. J Urol 1994.nlm.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7685427& dopt=Abstract Donovan JL. Urology 1991. J Urol 1995. Fozzard JL. de la Rosette JJ. A group of patients at increased risk of progression can be identified based on specific risk factors. Prostate-related symptoms in Canadian men 50 years of age or older: prevalence and relationships among symptoms. Janknegt RA. Rentzhog L.nlm.3 1.ncbi. Br J Urol 1997. UPDATE MARCH 2004 7 .fcgi?cmd=Retrieve&db=PubMed&list_uids=1714657& dopt=Abstract Norman RW.152:1467-1470. http://www.nih. Natural history of benign prostatic hyperplasia and risk of prostatectomy.132:474-479.nih. McFarlane G.nih. Impact of symptoms of prostatism on level of bother and quality of life of men in the French community. 6.gov/entrez/query. Gajewski JB. Fish D.2. Prevalence and detection of micturition problems among 2. J Urol 1968. LUTS = lower urinary tract symptoms. J Urol 1984.ncbi.gov/entrez/query.nih.nih.gov/entrez/query. http://www. Panser LA. Br J Urol 1994.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10559624& dopt=Abstract Barry SJ. http://www. Metter EJ.nlm. REFERENCES Chute CG.Benign Prostatic Hyperplasia. i.gov/entrez/query. which deteriorated back towards baseline during the course of the placebo-controlled trial. 36(Suppl 3):1-6. BPH disease management.
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In the Baltimore study. The effect of finasteride in men with benign prostatic hyperplasia. for each of the five clinical urinary symptoms studied (12). The risk of requiring subsequent surgery also varied with age. From the above. In most cases only insufficient marginal differences can be established (1).3). Bruskowitz RC. Fourth International Consultation on BPH. nonsmokers. obesity or high alcohol intake are risk factors in the development of clinical BPH. the likelihood of being treated surgically is about 3% (8. 1998. The need for surgery increases with symptoms and is twice as high in men with a high baseline-symptom score than for those with a low score (10). Khoury S et al. Epidemiology of benign prostatic hyperplasia: risk factors and concomitance with hypertension.219 men.3 1. Gormley GJ. the three predictive symptoms for surgery were change in size and force of the urinary stream. urine pH greater than 5. Plymouth: Health Publications. with a mean follow-up of 12 years.plymbridge.74(Suppl):18-22. Nevertheless. in a cohort of 2. REFERENCES Oishi K. Chronic conditions. Although more severe BPH symptoms (increased I-PSS and post-void residual) seem to be found in diabetic males even after age adjustment.nlm. the same study showed that increasing age was the predominant risk factor for surgery (8). it can be concluded that the risk of needing surgery for BPH increases with age and with the degree of clinical symptoms at baseline. 25-59. Surgical risk depends on age and the presence of clinical symptoms. Among older men. For men presenting with urinary retention. the fact that both conditions increase with age and can cause partially similar voiding symptoms. The Finasteride Study Group. Results of the different epidemiological studies are controversial. 10 UPDATE MARCH 2004 . three in 10 men may undergo surgery for this condition (2).35. Ultimately.4) was predictive of surgery (13).1 RISK FACTORS For developing the disease The aetiology of BPH is multifactorial. and those with three factors of 37%. 2. probably because of differences in sampling and methods of analysis. aged at least 40 years. low body mass index. Nocturia and changes in urinary stream seem to be the most important predictive symptoms. vasectomy. 2.2 For surgical treatment Although the number of surgical procedures for BPH has declined in the USA and Europe over the last decade (6). have been related to clinical BPH. Both of these risk factors are currently beyond prevention. Walsh PC. In the absence of clinical symptoms. only nocturia (odds ratio 2.ncbi. In: Denis L. Currently. those with two factors of 16%. Stoner E. the cumulative incidence for prostatectomy is 60% at 1 year and 80% at 7 years (11). Br J Clin Pract 1994. such as hypertension or diabetes. Epidemiology and natural history of benign prostatic hyperplasia. 2.com/ Boyle P.3 for hesitancy in young men (aged < 65 years). the odds ratio being 1. Bracken BR. Recently.nih. Men with one factor had a cumulative incidence of surgery of 9%. New Engl J Med 1992 Oct 22. McConnell JD.280 men.327:1185-1191.gov/entrez/query. Imperato-McKinley J. but given the frequent occurrence of these conditions in ageing men a large proportion of patients can be expected to suffer from such an association (2.nih. eds. Tenover JS et al. http://www. Adriole GL. Geller J. Boyle P.gov/entrez/query. the main predictor for surgery was the presence of urinary symptoms. The only true factors related to the development of the disease are age and hormonal status (4). and a history of kidney X-ray and/or tuberculosis. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=7519437& dopt=Abstract 2. it has been stated that diabetes and clinical BPH are associated more frequently than would be expected based on chance alone.nlm. pp. The crucial role of the testis has been recognized for more than a century and current research has extended into the field of molecular biology (5).fcgi?cmd=Retrieve&db=PubMed&list_uids=1383816& dopt=Abstract 2.9). showed a positive association with surgery for age. there is no strong evidence that smoking.8 for nocturia and 4. Paris. they still represent the second most common major operation in aged men (7). Barry JM et al. Multivariate analysis carried out on a sample of 16.ncbi. Griffiths K. In the Veterans Normative Aging Study. July 1997. sensation of incomplete voiding and digital rectal enlargement of the prostate. produces a considerable bias (3). http://www.
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9-49% of those with moderate or severe urinary symptoms reported interference with some of their daily activities. I-PSS and physiological measures measure different things. 3.g. For example.1. a summary or index score is generated which has been shown to be an accurate reflection of a man’s overall symptoms over the preceding month (4).purport to measure. However. mental health and perception of general health. there are numerous reports of symptom severity (as expressed by I-PSS) correlating poorly with peak urinary flow rate. a postal population survey among 217 men aged 55 years and over with LUTS showed that.5 Conclusions Evaluating symptom severity with a symptom score is an important part of the initial assessment of a man. 12 UPDATE MARCH 2004 .1. e. post-void residual volume. prostate size or pressure-flow relationships (1. A man with a pre-operative I-PSS of 17. It can be used to monitor change in symptoms over time or following an intervention. average flow rate. There is little evidence that physiological measures improve the chances of predicting a favourable symptomatic outcome. Numerous authors have reported and commented upon the poor correlations between I-PSS and other physiological variables. The association between the outcome of this population survey and the degree of ‘bothersomeness’ was stronger than that with the I-PSS symptom score. the proposed policy appears to hold true for patients with mild symptoms but is less reliable for men with moderate or severe symptoms (15). depending on the respondent’s activity. 8-10). 3. social functioning. vitality. Secondly. As men with mild symptoms have little room for improvement it is of little surprise that they do not experience high levels of symptom reduction following surgery. this question measures the extent to which patients tolerate their symptoms rather than evaluating their quality of life. moderate (8-19) and severe (20-35).1. Correlation of the self-reported score to intermittency or to the strength of stream was poor (5). Age and cultural factors may be important. there are statistical issues related to the clustering of values or data points. quality-of-life instruments have been used for clinical research. A validated symptom score assesses symptom severity. By adding the scores (with equal weighting) to its constituent questions. Patient with moderate symptoms might benefit from pharmacotherapy. Three categories of symptom severity were described: mild (0-7).4 Symptom score as outcome predictor Symptom score may be one of the more powerful predictors of symptomatic outcome (16). The I-PSS appears less reliable in men over 65 years old (6) and careful linguistic validation needs to be undertaken prior to its use in non-North American cultures (7). has an 87% chance of experiencing a substantial symptom reduction (17).1.1 International Prostate Symptom Score (I-PSS) The I-PSS has become the international standard. peak respiratory flow correlates poorly with patient’s own reports of the severity of their asthma. a 36-item short-form health survey (SF36) (14). are stable over time and are able to reflect clinically important changes (2). and in both predicting and monitoring the response to therapy. This lack of correlation has troubled many investigators and has led to some questions raised about the validity of the I-PSS. Using this score.1. One of the best known is the generic measure. The authors suggested that patients with mild symptoms were most appropriately managed by a watchful waiting approach. which will also result in poor correlation. 3. Increasing symptom severity was associated with worsening physical condition. It is a self-completed questionnaire used to measure general health status and quality of life. Correlations of similar magnitude have been seen in many other disease areas. 3. 3. The extent to which the selfreported scores reflect actual events has been questioned. It has been used in a number of studies addressing men with lower urinary tract symptoms. Firstly. It is helpful in allocating treatment. while patients with severe symptoms may derive most benefit from prostatectomy.3 Symptom score as decision tool for treatment Can symptom severity alone be used to allocate treatment? The US Agency for Health Care Policy and Research Guidelines (1) tried to do this. Although notions of appropriateness have not been well-studied. the Medical Outcomes Study.2 Quality-of-life assessment The impact of urinary symptoms on the quality of life is generally evaluated by means of question 8 of the I-PSS. or more. A number of health-related. It is derived from the American Urological Association (AUA) 7 score described by Barry and his colleagues in the early 1990s (3). The lack of correlation can be explained in two ways. Increasing ‘bothersomeness’ was associated with a worsening of all dimensions of general health status and quality of life. Men report nocturia with accuracy but tend to overstate daytime frequency.
PSA and DRE . Roehrborn et al. family history. This is why PSA is not considered as being cancer-specific. These parameters were also related with long-term changes in symptom scores and flow rates.5 • • • • Conclusions various factors (cancer.5 ng/mL per cm3 of cancer tissue.16) have shown that PSA and prostatic volume can be used to evaluate the risks of either needing surgery or developing acute urinary retention. every urologist will perform a DRE and most will measure the serum value of PSA. trauma.2. must also be considered when evaluating PSA values in men with LUTS (2. the greater is the probability of having prostate cancer the PSA level might predict the natural history of BPH.3). log-linear relationship and that PSA has a good predictive value for assessing prostatic volume (7). and therefore age-specific reference ranges must be adapted and interpreted according to race and ethnicity (4). since only minor variations in PSA reference ranges were found (5).14). Roehrborn et al. (15. Potter et al. elevated free PSA levels could predict clinical BPH.and have calculated the likelihood of detecting prostate cancer on sextant TRUS-guided biopsies among 2. 3. African-Americans with no evidence of prostate carcinoma have higher PSA values after their fourth decade of life. PSA. also found that prostate volume and serum PSA are significantly correlated and increase with advanced age (8). race.2 Prostate-specific antigen (PSA) measurement Before selecting the proper treatment for men with LUTS. have shown that PSA and prostate volume have an agedependent. DRE. prostatitis and after urinary retention.6 RECOMMENDATION The measurement of PSA is recommended when a diagnosis of prostatic carcinoma will change the decision made about which therapeutic option to use.2.2. independent of total PSA levels (17). In order to avoid unnecessary biopsies. may influence serum PSA levels the level of PSA correlates with the volume of the prostate gland the higher the PSA level. small and clinically insignificant changes occur after DRE. Both PSA forms were found to be able to predict the TRUS prostate volume (± 20%) in more than 90% of the cases (9). PSA will ‘leak’ into the circulation. I-PSS 3. This occurs when prostatic carcinoma is present but also in BPH. Other known causes of PSA serum elevations are biopsy of the prostate gland and ejaculation (1).2. Two other important factors. At the same time. In a recent epidemiological study. predictive nomograms have been developed by various groups. age. 3.g.2.6 RECOMMENDATIONS Recommended investigations: • Clinical history • Symptom assessment • Physical examination • Validated symptom score.3. age and race. For many years the value of 4ng/mL was considered as the upper normal limit of PSA (10) but lately a lower threshold of PSA for recommending prostate biopsy in younger men has shown to improve the clinical value of this test (11). Vesely et al. (12) have used three clinical parameters .2. Prediction of prostate volume can also be based on total and free PSA. they found that the serum PSA contribution from BPH was 0.2 PSA and prediction of prostatic volume Stamey et al. were the first to correlate PSA serum values and volume of prostatic tissue (6).age. 3. UPDATE MARCH 2004 13 . These nomograms are being constructed from variables such as age. In their studies in the late 1980s. 3. A recent community-based study of African-American men contradicts the beliefs of racial PSA differences. 3.4 PSA and prediction of BPH-related outcomes In a series of studies. infection. but organ-specific. BPH. In addition.054 men. e.1.3 PSA and probability of having prostate cancer The chance of having prostate cancer is strongly related with the serum value of PSA.30 ng/mL per gram of tissue and 3. PSA density and TRUS findings (13.1 Factors influencing the serum levels of PSA In cases where the architecture of the prostatic gland is disrupted. 3.
ncbi. Strawderman MS. Dicuio M. Ross LS. Babaian RJ. Taylor JM. Predictive modelling for the presence of prostate carcinoma using clinical. 13. N Engl J Med.nlm.nlm. Cancer 2003.gov/entrez/query. Encabo G.349:335-342. Barrera E.nlm. Bansal BSG.org/ Laguna P. Catalona WJ. Gould AL. Girman CJ.gov/entrez/query. Schottenfeld D. Effect of ejaculation on serum total and free prostate specific antigen concentrations.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=11394329& dopt=Abstract Cooney KA.57:91-96.nlm.gov/entrez/query.nih.nih.gov/entrez/query. Panser LA. Togami J. Serum prostate specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia. 7. prostate specific antigen and digital rectal examination as determinants of the probability of having prostate cancer.ncbi. Roehl KA.38:91-95. Urology 1997. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=9255295& dopt=Abstract Oesterling JE. Tinzl M. J La State Med Soc 2001. Jacobsen SJ. http://www. http://www. Montie JE.98:1849-1854. Relationship between age. 8. Partin A.ncbi. 12.nih.7 1. Wojno KJ.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=12944191& dopt=Abstract Morote J. Bartsch G. Urology 1999.nih.nlm. Alivizatos G. Lopez M. Klein T. symptom score and uroflowmetry in men with lower urinary tract symptoms. Dahlstrand C. 14 UPDATE MARCH 2004 . http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=10096388& dopt=Abstract Vesely S.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=11164150& dopt=Abstract Stamey TA. Damber JE. Serum prostate specific antigen in a community-based population of healthy men: establishment of age-specific reference ranges. Beer TM. D’ Amico AV.gov/entrez/query.37:322-328.nih. JAMA 1993.nlm.nlm. Prostate specific antigen. Racial variation in prostate specific antigen in a large cohort of men without prostate cancer. Cancer 2003. N Engl J Med 2001.nlm. http://jama. Kuntz KM. Chute CG.nlm. Partin AW. Brawer MK. Knutson T.50:239-243.ncbi. Freiha FS.gov/entrez/query. REFERENCES Herschman JD. 4.nih. Boyle P.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=14584066& dopt=Abstract Garzotto M.fcgi?cmd=Retrieve&db=PubMed&list_uids=12878740& dopt=Abstract Potter SR.157:1100-1104. Catalona WJ. and ultrasound parameters in patients with prostate specific antigen levels</= 10 ng/mL.3. Prediction of prostate volume based on total and free serum prostate specific antigen: is it reliable? Eur Urol 2000.fcgi?cmd=Retrieve&db=PubMed&list_uids=2442609& dopt=Abstract Roehrborn CG. 5. Horniger W. Curr Opin Urol 2000. 2003.nlm.153:184-189. de Torres IM.fcgi?cmd=Retrieve&db=PubMed&list_uids=10859448& dopt=Abstract Barry MJ. 6.nlm. Smith DS.98:1417-1422. A neurocomputational model for prostate carcinoma detection. Urology 2001.53:581-589. Testing for early diagnosis of prostate cancer. Sullivan J. N Engl J Med 1987.ncbi. http://www. Guess HA. Peters L. Prostate specific antigen and benign prostatic hyperplasia.ama-assn. Hudson RG.gov/entrez/query. Lieber MM. Age.gov/entrez/query.nih. http://www.nih.gov/entrez/query. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377318& dopt=Abstract Kalra P. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11333995& dopt=Abstract Punglia RS. Wei JT.ncbi.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=14508828& dopt=Abstract 2. 3.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=10650506& dopt=Abstract Eastham JA. Yang N.ncbi. Waldstreicher J. prostate volume. laboratory.ncbi. http://www. Prostate specific antigen as a serum marker for adenocarcinoma of the prostate.344:1373-1377. Effect of verification bias on screening for prostate cancer by measurement of prostate-specific antigen.gov/entrez/query.ncbi. Scand J Urol Nephrol. Niederberger CS. Taylor A.nih.nih. http://www. 14.gov/entrez/query. Richey W.ncbi. 9. Heeringa SG.10:3-8. Doerr KM. prostate-specific antigen. http://www. Alcser KH. Sartor O. Moparty B. McNeal JE. http://www. http://www. Age-specific distribution of serum prostate-specific antigen in a community-based study of African-American men.nih. Mori M. 2003.317:909-916.gov/entrez/query.ncbi.2. Urology 200.gov/entrez/query. Hay AR.270:860-866. 11. Redwine E. Hsieh YC. 10.
(8) reported a study in which voiding dysfunction of a non-neurogenic aetiology did not appear to be a risk factor for elevated BUN (blood urea/nitrogen) and creatinine levels. Proscar Long-term Efficacy and Safety Study.nih. Cook TJ. Gray T.fcgi?cmd=Retrieve&db=PubMed&list_uids=2466506& dopt=Abstract Mebust WK. Clinical predictors of spontaneous acute urinary retention in men with LUTS and clinical BPH: A comprehensive analysis of the pooled placebo groups of several large clinical trials. Oliver DO.15. it is probably cost effective to measure serum creatinine levels in all patients.1 CONCLUSIONS As it is difficult to select those with renal insufficiency from among evaluable BPH patients. http://www. Holtgrewe HL. It was also shown that neither the symptom score nor the quality-of-life assessment was associated with serum creatinine levels in patients with BPH. Cook TJ. Koch et al. UPDATE MARCH 2004 15 . Barry MJ.ncbi. This point is increasingly emphasized. it is probably unwise to avoid measuring serum creatinine levels in patients undergoing BPH evaluation in an effort to minimize costs. J Urol 1989. the measurement of creatinine is highly recommended. Peters PC. 3.3.3. http://www. This study suggests that it is not necessary to control the serum creatinine if voiding is normal.nlm. (9) also found that an isolated serum creatinine level could not predict the outcome after TURP. Earlier studies also showed a much higher mortality among BPH patients who underwent surgical treatment when renal insufficiency was present at the same time (3.ncbi. Eur Urol 2002. Urology 2001.fcgi?cmd=Retrieve&db=PubMed&list_uids=11489703& dopt=Abstract Meigs JB.fcgi?cmd=Retrieve&db=PubMed&list_uids=11520654& dopt=Abstract 3.gov/entrez/query.gov/entrez/query. it was shown that patients with BPH and renal insufficiency had a 25% risk of developing post-operative complications compared with the 17% risk in patients with normal renal function (2). diabetes and hypertension were the most probable causes of the elevated creatinine level among this group of patients. Comiter et al. A comparative study of 13 participating institutions evaluating 3. Davison AM.nih.nih. these figures might be overestimates as these studies involved patients undergoing surgical treatment (i.ncbi. Will EJ.ncbi. Mohr B. Late renal failure due to prostatic outflow obstruction: a preventable disease. Bevan A. McConnell JD. 16. In this way. A recent study evaluated 246 men presenting with BPH symptoms and found that approximately one in 10 (11%) had renal insufficiency (7). proper therapy can be offered to the right men and the costs of long-term renal damage and post-surgical complications can be avoided.e. However. http://www. as measured by an improvement in quality of life. Despite all of the above.fcgi?cmd=Retrieve&db=PubMed&list_uids=12121721&dopt=Abstract Roehrborn CG. Transurethral prostatectomy: immediate and postoperative complications. PLESS Study Group. This study also noted that it was rather rare to find patients with high creatinine levels due to bladder outlet obstruction only. Ten years ago.54:935-944. When renal dysfunction was present.3 Creatinine measurement It is well-accepted today that bladder outlet obstruction due to BPH might cause hydronephrosis and renal failure (1).gov/entrez/query. Malice MP. those with severe symptoms and with urinary retention). Collins MM.ncbi. Cockett AT.2 1. Narayan P. REFERENCES Sacks SH. (10) studied the additional value of renal ultrasonography in the assessment of patients with BPH and concluded that only those with an elevated creatinine level needed such an investigation. 17. Bergner D.6).nlm. we feel that this study does not address this issue. Saltzman B. Quezada WA. Bruskewitz et al. http://www.58:210-216.nlm. Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men.nlm. In the report from the AHCPR (11) and in the recommendations of the Fourth International Consultation on BPH (12).nlm.nih. http://www. Most studies have found that the incidence of azotaemia in men with BPH varies from 15-30% (5.nih. Aparicio SA.gov/entrez/query. Johnson-Levonas AO.fcgi?cmd=Retrieve&db=PubMed&list_uids=11908420& dopt=Abstract 2.gov/entrez/query.4). Br Med J 1989.42:1-6. Although the recently released MTOP’s data suggest that creatinine measurements might not be indicated.885 patients. Roehrborn CG.298:156-159. Waldstreicher J. J Clin Epidemiol 2001. 3. Storage (irritative) and voiding (obstructive) symptoms as predictors of benign prostatic hyperplasia progression and related outcomes.141:243-247. Girman CJ. as the use of certain α-blockers might cause additional problems in men with renal insufficiency. McKinlay JB.
nlm.gov/entrez/query.ncbi. Channel Islands. Geneva. 1996. Mukamel E. The outcome of renal ultrasound in the assessment of 556 consecutive patients with benign prostatic hyperplasia. However.fcgi?cmd=Retrieve&db=PubMed&list_uids=89133& dopt=Abstract Gerber GS..nlm. Agency for Health Care Policy and Research.fcgi?cmd=Retrieve&db=PubMed&list_uids=9186351& dopt=Abstract Bruskewitz RC. 10. Ezz El Din K.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490828& dopt=Abstract McConnell JD. we concluded that this inexpensive test which does not require sophisticated technical equipment should be incorporated in the primary evaluation of any patient presenting with LUTS. 5. Plymouth: Health Publications. July 1997. Valla SV.gov/clinic/medtep/bphguide. Servadio C. Serum creatinine measurement in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia. http://www. http://www. Reda DJ. Bales GT. J Urol 1995. In: Cockett AT et al. Cohen LH.nih. This is mainly due to the low specificity of this highly sensitive test.nlm. Barry MJ.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9120927& dopt=Abstract Koch WF.nih. Mebust WK. Holtgrewe HL.fcgi?cmd=Retrieve&db=PubMed&list_uids=4424347& dopt=Abstract Roehrborn CG. Khoury S et al.nih. Correa R et al. Occult progressive renal damage in the elderly male due to benign prostatic hypertrophy. J Urol 1997. US Department of Health and Human Services: Rockville.gov/entrez/query. 4. Transurethral prostatectomy in the azotemic patient. de la Rosette JJ. Urodynamic risk factors for renal dysfunction in men with obstructive and non-obstructive voiding dysfunction.27:403-406.com/ 3. Initial diagnostic evaluation of men with lower urinary tract symptoms. 11. http://www. http://www. 6.ncbi. MD. 8. However. 12. Firstly. it enhances the capacity to estimate prostate volume.nlm. Boner G. 179-265. Benign Prostatic Hyperplasia: Diagnosis and Treatment. eds.ncbi. AHCPR publication 94-0583. Testing to predict outcome after transurethral resection of the prostate. 3. Public Health Service. it can help to determine the co-existence of prostatic carcinoma. J Urol 1997. Karrison TG. as prostate size has been shown 16 UPDATE MARCH 2004 .4. Paris. such as malignancies.fcgi?cmd=Retrieve&db=PubMed&list_uids=9145973& dopt=Abstract Comiter GV. J Urol 1974.htm#bphimp Koyanagi T. Proceedings of the Third International Consultation on Benign Prostatic Hyperplasia (BPH). 9. Goldfisher ER. Phelan M. 155:186-189. 167-254. J Urol 1962. http://www. but also frequently in men with urinary tract infections. Overall. Quick Reference Guide for Clinicians. Foret JD. Wasson JH. Griffiths K. Valk WL. Artibani W. http://www. Nissenkorn I.ncbi. pp. microscopic urine analysis has not been accepted as a screening test for the early detection of severe urological diseases. analytical and microscopic urine analysis was considered to be mandatory.nih. In: Denis L.nih.157:1304-1308.gov/entrez/query. Barrett L. Secondly.3. 7. http://www. Bruskewitz RC.nlm. Debruyne FM.158:181-185.gov/entrez/query. causing unnecessary further diagnostic measures in a large number of patients.ahrq. 3. http://www. Valk WL. J Am Geriatr Soc 1979.gov/entrez/query. whether related or not to benign enlargement of the gland. de Wildt MJ.nlm. Scientific Communication International Jersey. and in at least 25% of patients with carcinoma of the bladder. 1998. and in this way may assist in choosing the right treatment.87:450-459.nih.ncbi. eds.5 Digital rectal examination (DRE) Digital rectal examination (DRE) is an important examination in men with LUTS for two reasons.ncbi.ncbi.gov/entrez/query. Urology 1997.4 Urinalysis Since LUTS is not only observed in patients with BPH. Factors influencing the mortality and morbidity of transurethral prostatectomy: a study of 2015 cases.fcgi?cmd=Retrieve&db=PubMed&list_uids=13908592& dopt=Abstract Melchior J. Sullivan MP.. Schacterle RS.plymbridge. pp. Proceedings of the Fourth International Consultation on BPH. it should be noted that there is little evidence in the literature to support this conclusion.112:643-646. http://www.nih. February 1994.49:697-702.1 RECOMMENDATION Urinalysis is recommended in the primary evaluation.
depends on the actual prostate volume.ncbi.1 DRE and cancer detection The positive predictive value (PPV) of a suspicious DRE to actually diagnose prostate cancer is 26-34% (1). Fifth International Consultation on BPH. used three clinical parameters. Screening decreases prostate cancer death: first analysis of the 1988 Quebec prospective randomized controlled trial. but proper training is needed.ncbi. Roehrborn has analyzed the data from four studies in which estimations of prostate volume by DRE were compared with those performed by TRUS (9).5. DRE is useful in evaluating the size of the prostate gland and also in order to exclude other pelvic pathologies.3 1.38:83-91.. Gomez JL. and digital rectal examination as determinants of the probability of having prostate cancer. age. Horniger W. http://www. In: Chatelain C. Potter et al. 3. particularly if the volume was greater than 30 mL.nih. Belanger A.fcgi?cmd=Retrieve&db=PubMed&list_uids=9973093& dopt=Abstract 2.57:1100-1104. an estimation of the prostate gland volume will help the urologist to select the most suitable form of treatment with the lowest cost and best outcome. it was concluded that underestimation of DRE increased with increasing TRUS volume. Candas B.gov/entrez/query. In the “Quebec” (3).g.5. Bartsch G. Response to certain types of therapy. These figures are based on screening studies and it is believed that DRE will have a higher PPV for cancer among men with LUTS.21) (7). is recommended. pain. Roehrborn developed a model of visual aids to help urologists predict prostate volume more accurately (10). Plymbridge Distributions. to determine the probability of having prostate cancer and constructed a nomogram to help in the decision whether or not to perform a prostate biopsy. For this reason. was abandoned (6).4.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377318& dopt=Abstract Labrie F. Age. DRE results were not a significant predictor of prostate cancer (P=0. In this study. Khoury S. Bosch J.gov/entrez/query. In the Prostate. 3. 3.nlm. McConnell J eds. 169-188. DRE has been used as an ancillary screening tool. Foo S. Correct estimation of the prostatic volume by DRE is not an easy task and therefore investigators for the PLCO (Prostate.com/ Potter SR. such as surgery. 3. Partin AW. Dupont A. Similar models to assist training for DRE examinations have been proposed by other groups as well (11). Benign prostatic hyperplasia. Recommendation: DRE is recommended in the evaluation of men with LUTS. PSA and DRE. Although different methods and criteria were used in the four studies.plymbridge. Frand I. prostate-specific antigen. They concluded that both methods were equal in completeness of examination. e. Colorectal and Ovarian Cancer) trial have described quality-control procedures for DRE examination (8). In the European Prostate Cancer Detection Study (EPCDS) of 1. Diamond P. Suburu RE. pp. In 1997 the use of DRE in the ERSPC trial as a screening test. and embarrassment (12). Ackerman R. 2. DRE had a significant influence on the likelihood of a positive biopsy in all PSA and age ranges (2). Cusan L. 2000. http://www. as these patients are usually older. Urology 2001. Cidre J. Tinzl M.nlm.5. UPDATE MARCH 2004 17 . Frank et al.nih. Denis L. It is well-accepted that TRUS is more accurate in determining prostate volume than DRE. Colorectal and Ovarian (PLCO) screening trial and in the European Randomized study of Screening for Prostate Cancer in Europe (ERSPC). In patients for whom invasive therapy. have compared the knee-elbow to the left-lateral position of the patient in examining and evaluating the prostate. the “Innsbruck”(4) and the “Olmsted County”(5) screening trials. Lung.to be a determining factor for certain treatment options. CONCLUSIONS AND RECOMMENDATION DRE has been used in all major screening trials but its actual impact in the early diagnosis of PCa has been questioned. http://www. Lung. 1.5.051 men. Prostate 1999. Foo K. 3. finasteride. DRE has been used in the screening process.2 DRE and prostate size evaluation A number of options are currently available for the treatment of patients with BPH. REFERENCES Resnick M. Levesque J. Finally.
7. http://www.ncbi.gov/entrez/query. O’Brien B. Schonitzer D. Boyle P. Interexaminer reliability and validity of a three-dimensional model to assess prostate volume by digital rectal examination. mass screening in the Federal State of Tyrol. Thomas K. Austria. Lung. Remzi M.9.ncbi. http://www. a randomized study comparing the knee-elbow and the left-lateral position.nlm.nlm.161:529-533. Urol Clin N Am 2003. Ideally.fcgi?cmd=Retrieve&db=PubMed&list_uids=9915441& dopt=Abstract Schröder FH. Control Clin Trials 2000.nih. J Urol 2000.gov/entrez/query.6. Tyrol Prostate Cancer Screening Group. 12.nlm.Screening for prostate cancer. Katusic SK. Emberton M.nlm. J Urol 1999. Minnesota. Wilkinson and Wild (12) reported on 175 patients with LUTS with no urinary retention and identified no abnormalities on renal ultrasound and IVU that would have altered the therapeutic 18 UPDATE MARCH 2004 .nih.nlm.ncbi. Severi G. an imaging modality for patients with LUTS should provide both imaging of the urinary tract and demonstrate the morphological effects of prostate pathology upon the rest of the lower and/or upper urinary tract. Urology 1998. Accurate determination of prostate size via digital rectal examination and transrectal ultrasound.fcgi?cmd=Retrieve&db=PubMed&list_uids=11189690& dopt=Abstract Roehrborn CG. Oliver S.87:331-333.fcgi?cmd=Retrieve&db=PubMed&list_uids=11549491& dopt=Abstract Roberts RO. http://www. Zlotta AR. 5. Decline in prostate cancer mortality from 1980 to 1997.nih. Horninger W.13).nlm.6 Imaging of the urinary tract Imaging of the entire (including the upper) urinary tract. Popescu V.57:1087-1092. Fagerstrom RM.nih. Colorectal and Ovarian Cancer Screening Trial Project Team. 3. Lieber MM.fcgi?cmd=Retrieve&db=PubMed&list_uids=11251525& dopt=Abstract 3. Urology 2001. http://www. In parallel with endoscopy. Ghawidel K.fcgi?cmd=Retrieve&db=PubMed&list_uids=10737484& dopt=Abstract Weissfeld JL. http://www. 10. http://www. Girman CJ. Virtual reality-based training for the diagnosis of prostate cancer.1 Upper urinary tract A recent survey of 24 urological centres in the UK found that 21 of 24 centres (79%) used either intravenous urography (IVU) or sonography.ncbi. particularly prior to prostate surgery. 58:417-424. Prostate. Schulman CC. 21(Suppl 6):S390-399.nlm.gov/entrez/query.gov/entrez/query. Basharkhah A. and that 16 of 24 centres (67%) used plain films as routine procedures prior to prostatectomy (14).ncbi. the role of routine imaging of the upper and lower urinary tract in all patients with LUTS has been increasingly questioned in recent years (5. Marberger M.46:1253-1260.gov/entrez/query. http://www. Colorectal and Ovarian (PLCO) Cancer Screening Trial.fcgi?cmd=Retrieve&db=PubMed&list_uids=9586592& dopt=Abstract Roehrborn CG. Sech S.051 men.163:1144-1148.gov/entrez/query.ncbi.nih. IEEE Trans Biomed Eng 1999.51(Suppl 4A):19-22.ncbi.nih.gov/entrez/query. 11.ncbi. Montoya J. have been reported in the USA (15). Rhodes T. Similar findings. Bartsch G. Urology 2001. Robertson C. BJU Int 2001.6. Quality control of cancer screening examination procedures in the Prostate. Weiss RE. 8. Choong S.nlm. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=10513131& dopt=Abstract Frank J.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377314& dopt=Abstract Burdea G. 6. Patounakis G.nih. Couch or crouch? Examining the prostate. has been an integral part of the diagnostic assessment of elderly men with LUTS due to BPH during past decades (1-12).gov/entrez/query. Jacobsen SJ. Optimal predictors of prostate cancer in repeat prostate biopsy: a prospective study in 1. The most common argument in favour of routine imaging of the upper urinary tract was ‘not to miss anything’. Reissigl A. and an update on incidence trends in Olmsted County.fcgi?cmd=Retrieve&db=PubMed&list_uids=12735501& dopt=Abstract Djavan B. Prostate cancer mortality after introduction of prostate-specific antigen.ncbi. 9.nih. particularly a high rate of IVU.30:239-251. Data from several large-scale studies have led to doubts concerning the role of routine upper urinary tract imaging in patients with LUTS. Lung. Bergstaralh EJ.4.gov/entrez/query. Oberaigner W. http://www.nih. Taylor R. Klocker H. Andrews S.
000 (17. including 778 patients with LUTS due to BPH. Hydronephrosis was found in 7.4 Prostate Imaging of the prostate is performed to assess: • prostate size • prostate shape • occult carcinoma • tissue characterization. who performed renal ultrasound scans in a consecutive series of 556 elderly men with LUTS.5%) had hydronephrosis (13).4 years (16).81% and 0.51% of IVU and of ultrasonography patients. UPDATE MARCH 2004 19 . Low-osmolar contrast material (LOCM) resulted in a six-fold improvement in safety compared with high-osmolar contrast material (18). 3.0002. A total of 6. These data need to be correlated with the incidence of renal cell cancer in the general population. A recent review was carried out on data from 25 published reports on the findings of IVU. and solid renal masses were identified in 0. (20) concluded that bladder wall thickness appeared to be a useful predictor of bladder outlet obstruction. Manieri et al. The authors concluded that renal ultrasound is only indicated in patients with an elevated serum creatinine level and/or post-void residual urine volume (13). respectively.56%.8% of ultrasonography patients.8%. Reliable data on inter.58 rem. Renal cysts were seen in 4.3%. IVU or renal ultrasound Several arguments support the use of renal ultrasound. Serum creatinine levels appeared to be correlated with dilatation of the renal pelvis. it has been estimated that the risk of elderly men developing renal cell cancer ranges from 0. 14 (2.18).000.approach. are still lacking and. in patients with pre-existing renal failure. A number of tumours were identified during endoscopy that had been overlooked during imaging.1 million patients revealed an incidence of adverse effects due to contrast medium in approximately 6% of patients. post-void residual urine volume and prostate • costs • avoidance of irradiation • no side-effects. usually seen in about 1% of cases.18% to 0.6. Overall. as well as reproducibility. The average radiation dose is 1.3 Urethra Retrograde urethrography gives only indirect information on the effect of benign prostatic enlargement (BPE) on adjacent structures.. only limited urodynamic information.6. Similar data have been published by Koch et al.6.000-200. measurement of bladder wall thickness is currently not part of the recommended diagnostic work-up of patients with LUTS. These figures are comparable with the results of large-scale studies in elderly men with LUTS and indicate that the incidence of renal carcinoma is not increased in these patients. an incidence of serious adverse effects in 1 in 1. 3. the measurement of bladder wall thickness by transabdominal ultrasound has gained considerable interest as a non-invasive tool to assess bladder outflow obstruction (19). 3. therefore.6% of IVU and 6. at best.3% of all IVUs and 70% of all the ultrasound studies performed were normal. 74. Other malignancies found during routine examination of the urinary tract are bladder and ureteral cancer. Furthermore.2 Lower urinary tract Urinary bladder voiding cysto-urethrogram This investigation suffers from the fact that the information on the lower urinary tract is only indirect and gives. and a risk of dying from an allergic reaction of 1 in 100. the use of LOCM reduces the risk of nephrotoxicity (18). Based on several autopsy and epidemiological studies. The mean patient age in these series was 68. More recently.131 men from nine ultrasound series were involved. most of the cancers suspected during imaging were not identified during endoscopy. Among the most important are: • better characterization of renal masses • possibility of investigating the liver and retroperitoneum • simultaneous evaluation of the bladder.3% and 0. 30% had measurable degrees of renal insufficiency. with a value exceeding that of uroflowmetry. IVU adverse events A review of 10 reported studies involving over 2. Poor or no renal function was found in 12. However.5% and 15. It is therefore not recommended in the routine diagnostic work-up of elderly men with LUTS.and intra-observer variability.
gov/entrez/query.gov/entrez/query.120:685-686. Prostate volume can be estimated by serial planimetry. Mee D.nih. Donnelly B. the shape of the prostate is changed by the continuous growth of the transition zone. 4.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=1131499& dopt=Abstract Morrison JD.nih. However. Standgaard L. 20 UPDATE MARCH 2004 . More likely causes include bladder cancer or prostate cancer. only imaging of the prostate by TRUS.nlm.ncbi.7:65-67. validation of these data by others is still lacking.34:239-241.5 1. 3.fcgi?cmd=Retrieve&db=PubMed&list_uids=6161822& dopt=Abstract DeLacey G.nlm. Preoperative evaluation of patients with bladder outlet obstruction with particular regard to excretory urography. 8.gov/entrez/query.nih.gov/entrez/query. http://www. Routine intravenous urograms prior to prostatectomy.nlm. Prostate shape Watanabe (25) introduced the concept of the presumed circle area ratio (PCAR). J Urol 1961.ncbi.ncbi. This is based on the usual normal triangular-shaped appearance of the prostate in the absence of benign prostatic enlargement (BPE).6. In BPE. and that BPE is very unlikely to be the cause of the post-void residual urine volume.fcgi?cmd=Retrieve&db=PubMed&list_uids=2451969& dopt=Abstract Donker PJ.ncbi.Choice of imaging modalities The prostate can be imaged using: • transabdominal ultrasound • TRUS • computed tomography (CT) and magnetic resonance imaging (MRI) (including transrectal MRI).86:171-172.nih.gov/entrez/query. 5. Help or habit? Excretion urography before prostatectomy.fcgi?cmd=Retrieve&db=PubMed&list_uids=2429536& dopt=Abstract Butler MR. Prostate size A large body of evidence documents the accuracy of TRUS in calculating the volume of the prostate (22.ncbi. Jacobsen O. Br J Clin Pract 1980. Urwiller RD.ncbi.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=6767041& dopt=Abstract 2.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=6158963& dopt=Abstract Pinck BD. Urology 1978. ellipsoid) and three-dimensional methods (23). http://www.147:957-959. is currently used (21).296:965-967.nih. Excretory urography in patients with prostatism. http://www. Blandy JP.nlm. 10.123:390-391. Pantos TG. http://www. 6.46:73-76. orthogonal plane.nih.gov/entrez/query. 3. http://www.nih. Is urography necessary for patients with acute retention of urine before prostatectomy? Br J Urol 1974. Jasper P.nih.nlm. http://www. REFERENCES Andersen JT.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=731806& dopt=Abstract Marshall V. Am J Radiol 1986. http://www. if this is not available.11:225-230.gov/entrez/query. Corrigan MJ. The diagnostic value of intravenous pyelography in infravesical obstruction in males.ncbi. Johnson S. Pre-prostatectomy excretory urography: does it merit the expense? J Urol 1980.gov/entrez/query. Eur Urol 1981. Intravenous urography in evaluation of acute retention. 9.fcgi?cmd=Retrieve&db=PubMed&list_uids=715976& dopt=Abstract Christofferson I. Prostatism: how useful is routine imaging of the urinary tract? Br Med J 1988. TRUS has significantly higher accuracy than that of cystoscopy. Moller I. Komaranchat A. or. Katz PG. Scand J Urol Nephrol 1977.23). In daily routine practice.75 or less than 75.gov/entrez/query. The prostate volume estimated by DRE and endoscopy is known to underestimate prostates over 40 mL in size (24). http://www. Excretory urography: a superfluous routine examination in patients with prostatic hypertrophy. J Urol 1978. Watanabe reported that pathological residual urine is seen if the presumed circle area ratio (PCAR) is greater than 0.12:464-466. by transabdominal ultrasound. Bundrick TJ. IVU. rotational body (single plane. http://www. rectal examination and or urethral pressure profile (24). however.nlm.nlm. Kakiailatu F.nlm. 7. Singh M.fcgi?cmd=Retrieve&db=PubMed&list_uids=74088& dopt=Abstract Bohne AW.
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Eckhardt MD. and data generated by voiding charts. Men with LUTS and normal Qmax are more likely to have a non-BPH-related cause of their symptoms. REFERENCES Abrams P.fcgi?cmd=Retrieve&db=PubMed&list_uids=8908664& dopt=Abstract Reynard JM. Donavan JL. Frequency volume charts: an indispensable part of lower urinary tract assessment.nlm. de la Rosette JJ. for example.38:45-52.ncbi. Prins A. Nocturia and polyuria in men referred with lower urinary tract symptoms. http://www.nlm.nlm. such as frequency and nocturia.gov/entrez/query.7.fcgi?cmd=Retrieve&db=PubMed&list_uids=11173938& dopt=Abstract Blanker MH. Schäfer W. maximum flow rate (Qmax). Boon TA. non-invasive test that can reveal abnormal voiding.3. Data from frequency-volume charts versus symptom scores and quality of life score in men with lower urinary tract symptoms due to benign prostatic hyperplasia. Eur Urol 2000. It is a simple.nih.7. Rittig S.nlm.gov/entrez/query.164:1201-1205. Abrams P. Mortensen JT. A frequency volume chart is non-invasive . Bohnen AM. 3. http://www. Eckhardt MD. 5. and this information should be interpreted by the physician to exclude artifacts (1-3). Bernsen RMD.nih. Serial flows (two or more) with a voided volume exceeding 150 mL are recommended to get a representative flow rate.2). Eur Urol 2001. http://www. Br J Urol Int 1999. http://www.gov/entrez/query. 22 UPDATE MARCH 2004 . Voiding charts allow.nih. Analysis and reliability of data from 24-hour frequency-volume charts in men with lower urinary tract symptoms due to benign prostatic hyperplasia. BOO can only be diagnosed with a pressure flow study (pQs) (see section 3. Gisholf KWH. Flow rate machinery provides information on voided volume. recent data indicate that a 24-hour voiding chart is sufficient and that longer time periods provide only little additional information (3).82:619-623. the identification of patients with nocturnal polyuria.ncbi.7 Voiding charts (diaries) Voiding charts (diaries) are simple to complete and can provide useful and objective clinical information (1. Yang Q.ncbi. inexpensive. http://www. http://www. Peters TL. 4. 6.fcgi?cmd=Retrieve&db=PubMed&list_uids=10859441& dopt=Abstract Van Venrooij GEPM. The ICS-BPH study: uroflowmetry.gov/entrez/query. van Venrooij GEPM.ncbi. one of the causes of nocturia in elderly men (4-6). J Urol 2000.nih. Scand J Urol Nephrol 1996. assessed using a 7-day frequency-volume chart.nih. Lim AT. and provides important insights into LUTS. There is no standard frequency volume chart available. 3. Osawa D. 3.8 Uroflowmetry Uroflowmetry is recommended as a diagnostic assessment in the work-up of patients with LUTS and is an obligatory test prior to surgical intervention.fcgi?cmd=Retrieve&db=PubMed&list_uids=10992366& dopt=Abstract Matthiesen TB.179:47-53.10) and flow rates should interpreted with caution in particular as elderly men with LUTS have age-related urodynamic changes (4).fcgi?cmd=Retrieve&db=PubMed&list_uids=9839573& dopt=Abstract Gisolf KWH. There is a close correlation between LUTS.39:42-47. men with a Qmax less than 10 mL/sec are more likely to have BOO and are therefore more likely to improve with surgery. However. Boon TA. Klevmark B. 61% for the time of voids and 68% for episodes of nocturia (2). 3.83:1017-1022. Normal voiding patterns and determinants of increased diurnal and nocturnal voiding frequency in elderly men. Djurhuus JC. The ICS BPH study reported an exact correlation in 41% of the number of voids. Br J Urol 1998. lower urinary tract symptoms and bladder outlet obstruction. Dabhoiewala NF.nlm.nlm. as assessed by symptom scores.gov/entrez/query. However.ncbi. average flow (Qave) and time to Qmax. Groeneveld FPMJ.ncbi.2 1.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=10368248& dopt=Abstract 2. Bosch JLHR.1 CONCLUSIONS Recording of a 24-hour frequency volume chart in the course of an initial consultation is considered to be a standard investigation.gov/entrez/query.
10.nlm. Blaivas JG. such as in elderly patients. 3.nlm.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9471041&query_hl=80&itool=pubmed_docsum Madersbacher S. It should be calculated by measurement of the bladder height. James ED. Jensen (15).3. it is not possible to establish a PVR “cut-point” for treatment decision. Zerbib M. 3.9 Post-void residual volume Post-void residual (PVR) urine measurement is recommended during initial assessment. Stulnig T. J Urol 1996. Klingler HC.nih. Flow rates only determine the probability of obstruction. Detrusor pressure at the point of maximum flow must be recorded in order to diagnose obstruction.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7678870&query_hl=71&itool=pubmed_docsum Witjes WP. Schatzl G.1 1. (17) all report improved outcomes in patients who are obstructed prior to surgery.ncbi. Andersen JT. The methodology for performing pressure-flow studies is now standardized (7) and requires simultaneous recording of both intravesical and intra-abdominal pressure. and should be used in clinical practice. J Med Eng Technol 1987. they remain optional. Large PVR volumes (> 200-300 mL) may indicate bladder dysfunction and predict a less favourable response to treatment. Abrams and Griffiths (9) and Rollema and Van Mastrigt (URA – Urethral Resistance Index) (10) are most commonly used. UPDATE MARCH 2004 23 . and length obtained by transabdominal ultrasonography. http://www. Age-related urodynamic changes in patients with benign prostatic hyperplasia. Maximum urinary flow rate by uroflowmetry: automatic or visual interpretation. Suhel PF. http://www. (14).156:1662-1667.gov/entrez/query.ncbi.13). Debruyne FMJ. 3. For this reason. Stoner E. de la Rosette JJ. Those developed by Schafer (8). Vignoli GC. Urodynamic equipment: Technical aspects. Bruskewitz R. individuals with low voided volumes.gov/entrez/query. This makes it more difficult to judge the influence of infravesical obstruction on lower urinary tract symptoms in patients with BPH.nlm. Siroky MB. In specific patient subgroups.nlm. Flow rates may be particularly limited in predicting obstruction in specific situations.149:339-341. Computerized artefact detection and correction of uroflow curves: Towards a more consistent quantitative assessment of maximum flow. residual urine is not a contraindication to watchful waiting or medical therapy.gov/entrez/query. accurate and non-invasive method.1 Outcome Pressure-flow studies do not predict the response to medical therapy and have no role in this setting. J Urol 1993. (16) and Langen et al. debate continues as to their role in predicting treatment outcomes. but the probability is lower. Patients with low-pressure and low-flow urodynamics may also have a successful outcome following prostatectomy. Because of large test-retest variability and lack of outcome studies. as well as in the presence of neurological disease. Marberger M. width. and they all correlate closely.33:54-63. Studies reported by Neal et al. Although pressure-flow studies are the only means of diagnosing obstruction accurately. based on pressure-flow studies.ncbi.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2956425&query_hl=67&itool=pubmed_docsum Grino PB. or men with a Qmax of more than 10mL/s. 3. Wijkstra H. it is known that patients with high-pressure and low-flow urodynamics have the best outcome from prostatectomy. Kramer AE. Sterling AM. However.gov/entrez/query. Cook T. Most work in relation to pressure-flow studies and treatment of LUTS due to BPO relates to TURP. whereas pressure-flow studies can categorize the degree of obstruction and identify patients in whom a low flow rate may be due to a low-pressure detrusor contraction. the case for pressure-flow studies is stronger.nih.ncbi. Abrams et al. This is a simple. http://www. Recent methodological studies looking on intra-individual variation in pressure-flow results as well as intra. (12. REFERENCES Rowan D. Different nomograms exist with which to classify patients into categories of obstruction. http://www.10 Urodynamic studies Pressure-flow studies are regarded as an additional diagnostic test and are considered optional by both the AUA guideline panel on management of benign prostatic hyperplasia (2003) (1) and the Fifth International Consultation on BPH (2). The ICS (International Continence Society) nomogram (11) has now been adopted as the standard nomogram to aid comparison of different data sets. Schmidbauer CP. Robertson et al. 4.11:57-64.8. Geffriaud C. and because pressure-flow studies are regarded as invasive. Eur Urol 1998. Still.und inter-individual observer accuracy in interpretation of pressure-flow curves have demonstrated a considerable methodological variation (3-6).fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8863566&query_hl=83&itool=pubmed_docsum 2.
fcgi?cmd=Retrieve&db=PubMed&list_uids=9021786& dopt=Abstract Neal DE. J Med Eng Technol 1987. Br J Urol 1979.gov/entrez/query.ncbi. Styles RA. Relationship between voiding pressure. Sonke GS. van Mastrigt R. Smith A. J Urol 2001. Neurourol Urodyn 2000. Neurourol Urodyn 2000.3.ncbi.nlm. Atan A.fcgi?cmd=Retrieve&db=PubMed&list_uids=3427341& dopt=Abstract Neal DE.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=11071695& dopt=Abstract Eri LM. Produced by the International Continence Society Working Party on Urodynamic Equipment.ncbi.gov/entrez/query. J Urol 2003.nih. Powell PH.nlm. Sharples L. J Urol 1993.ncbi. AUA practice guideline committee. 3.fcgi?cmd=Retrieve&db=PubMed&list_uids=10797579& dopt=Abstract Rowan D.gov/entrez/query. Kallestrup E. Nordling J. Paris. 12.149:574-577.nih. Webb RJ.and Inter-investigator variation in the analysis of pressure-flow studies in men with lower urinary tract symptoms. 2001.nlm. Neurourol Urodyn 1997.51:129-134. 4.nlm. p.gov/entrez/query.170:530-547. Neurourol Urodyn 1999. 10.gov/entrez/query. AUA guidelines on management of benign prostatic hyperplasia (2003). symptoms and urodynamic findings in 253 men undergoing prostatectomy.nlm. Khoury S. McConnell J eds. van Mastrigt R. 24 UPDATE MARCH 2004 . International Continence Society Subcommittee on Standardization of Terminology of Pressure-Flow Studies.nih.19:221-232.nih. http://www.ncbi. Plymouth: Health Publications. Improved indication and follow-up in transurethral resection of the prostate using the computer program CLIM: a prospective study. Kortmann BB. Suhel PF. Ramsden PD. http://www. Kramer AE. Gleason D.nih. Variability of pressure-flow studies in men with lower urinary tract symptoms. http://www.ncbi.ncbi. Nordling J. Holm NR.nih.nlm. 6. de La Rossette JJ. 9. Griffiths DJ. Denis L. Spangberg A.16:1-18. Intra. Powell PH. Rollema HJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=1377287& dopt=Abstract Griffiths D. Verbeek AL. Urodynamic equipment: technical aspects. Chapter 1: Diagnosis and treatment recommendations.gov/entrez/query.nih.18:205-214. Hofner K.gov/entrez/query. Kiemeney LA. Proceedings of the Fifth International Consultation on BPH.nih. 524. 3. de La Rosette JJ.nlm.ncbi. The assessment of prostatic obstruction from urodynamic measurements and from residual urine.299:762-767.2 CONCLUSIONS Pressure-flow studies remain optional tests in straightforward cases presenting for the first time with LUTS. 8.nih.gov/entrez/query.nlm. Berge V.165:1188-1192. Br J Urol 1987.60:554-559. These studies are the most useful investigations available for the purpose of counselling patients regarding the outcome of surgical therapies for BPH. Test-retest variation of pressure flow parameters in men with bladder outlet obstruction. Wessel N. Foo KT.3 REFERENCES 1.19:637-651. Olsen L. http://www.10. 11.ncbi. Standardization of terminology of lower urinary tract function: pressure-flow studies of voiding.11:57-64.fcgi?cmd=Retrieve&db=PubMed&list_uids=10338441& dopt=Abstract Sonke GS. 7.nlm.gov/entrez/query.nlm. Thong J. http://www. July 2000. 13. 5. Wijkstra H.fcgi?cmd=Retrieve&db=PubMed&list_uids=12853821& dopt=Abstract Chatelain C.ncbi.gov/entrez/query. Ramsden PD. http://www.com/ Hansen F.fcgi?cmd=Retrieve&db=PubMed&list_uids=2956425& dopt=Abstract Schafer W. J Urol 1992.fcgi?cmd=Retrieve&db=PubMed&list_uids=2508914& dopt=Abstract 2.ncbi. http://www. http://www. Abrams P. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11257668& dopt=Abstract Kortmann BB. http://www.10. Debruyne F. Outcome of elective prostatectomy. James ED. http://www. Sterling AM. http://www.148:111-115.nih. The ICS nomogram should be used for the diagnosis of obstruction in order to standardize data for comparative purposes.gov/entrez/query.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=465971& dopt=Abstract Rollema HJ.plymbridge. Pressure-flow studies: Short term repeatability. A new concept for simple but specific grading of bladder outflow condition independent from detrusor function. Styles RA. BMJ 1989. urethral resistance and urethral obstruction.
1 LUTS caused by bladder outlet obstruction Voiding complaints in elderly men are most frequently caused by BPH resulting in benign prostatic obstruction. 3. Neurourol Urodynam 1989. the role of BPH in the voiding dysfunction experienced by elderly men is often unclear (1).nih. UPDATE MARCH 2004 25 . 75-84. However. 3.4% after urethral instrumentation alone.155:506-511. (5) evaluated 122 patients of mean age 64 years with LUTS using three post-operative uroflowmetry tests and symptom evaluation. 15. 1992. All 21 patients who presented with diverticula had an 'obstructive' peak flow rate prior to surgery. pp.4 Relationship between trabeculation and symptoms Simonsen et al.3 Relationship between trabeculation and peak flow rate Shoukry et al.fcgi?cmd=Retrieve&db=PubMed&list_uids=86617& dopt=Abstract Jensen KM-E.11 Endoscopy The standard endoscopic procedure for diagnostic evaluation of the lower urinary tract (urethra. J Urol 1979. urethrocystoscopy may provide information about the cause. size and severity of obstruction. New York: Springer-Verlag.. 16.2 Morbidity of urethrocystoscopy Berge et al. The results of prostatectomy: a symptomatic and urodynamic analysis of 152 patients. Clinical evaluation of routine urodynamic investigations in prostatism. it was noted that trabeculation significantly increased with increasing age (p < 0. Abrams PH. http://www. 21% of 73 patients with mild trabeculation and 12% of 40 patients with marked trabeculation on cystoscopy. 3. Benign Prostatic Hyperplasia: Conservative and Operative Management. Whiteside CG. indicated by the presence of muscular trabeculation and the formation of cellules as well as diverticula • formation of bladder stones • retention of (post-void residual) urine. while moderate-to-severe trabeculation was predictive of larger prostate size and reduced flow rate (8). 3. Urodynamic assessment in patients undergoing transurethral resection of the prostate: a prospective study.gov/entrez/query. Schafer W. Conventional urodynamics and ambulatory monitoring in the definition and management of bladder outflow obstruction.ncbi. Feneley RC.nih.gov/entrez/query. When patients were grouped by age. prostatic occlusion of the urethra and estimated prostate size (3). prostate. This obstruction has a critical role in altering voiding. It is generally accepted that therapies aimed at removing obstruction will relieve LUTS in most men. Turner-Warwick RT.5) between the degree of trabeculation. bladder neck and bladder) is a urethrocystoscopy.11.nlm. J Urol 1996. as graded from I to IV. Conversely. patency of the bladder neck. but symptoms may be negligible if the degree of obstruction is not severe. Urethrocystoscopy was also performed in these patients.14. Robertson AS.11. In: Jakse G. (7) found a correlation between the presence of trabeculation and the number of obstructive symptoms.11. (4) studied 85 patients and found that the risk of acquiring clinically significant urinary tract infection was 2. none of the trabeculation ratings were predictive of symptom severity.fcgi?cmd=Retrieve&db=PubMed&list_uids=8558647& dopt=Abstract Langen PH. In another study. Thus. eds. Patients with BPH or other forms of bladder outlet obstruction may develop certain signs seen by urethrocystoscopy.11. and the peak pre-operative flow rate in 39 men aged 53-83 years with LUTS. These signs may include: • enlargement of the prostate gland with visual obstruction of the urethra and the bladder neck • obstruction of the bladder neck by a high posterior lip of the bladder neck • muscular hypertrophy of the detrusor muscle. Jakse G. Several studies have addressed these issues. Griffiths C.nlm. Neal DE. Anikwe (6) showed that there was no significant correlation (p > 0. This investigation can confirm causes of outflow obstruction while eliminating intravesical abnormalities. resulting in significant (pathological) changes in the urinary tract of some patients and symptoms alone in others. indicating the presence of such obstruction. BPH may be associated with a relatively small prostate and marked obstructive symptoms if the obstructing tissue originates exclusively within the central zone of the peri-urethral gland area (2). The pre-operative peak flow rate was normal in 25% of 60 patients who had no bladder trabeculation. Hyperplasia may be associated with striking lateral lobe enlargement.ncbi.8:545-578. http://www.5). 3. 17. There appeared to be a trend towards lower peak flow rates in men with higher degrees of trabeculation. Farrar DJ.121:640-642. et al.
Bladder stones are a clear indicator of bladder outlet obstruction. without carrying the risks of invasive urethrocystoscopy. peak flow rate or prostate size. such as cystography.8 Bladder stones and obstruction There is no doubt that the presence of bladder stones can be assessed accurately by urethrocystoscopy. no final decision about the value of cystoscopy in the assessment of bladder diverticula can be made. Quirinia and Hoffmann (12) reported on 104 patients with BPH of whom 51% had diverticula by cystography.5).6 Relationship between trabeculation and obstruction El Din et al.11.7 Bladder diverticula and obstruction The detection of large bladder diverticula might be of therapeutic importance. are equally sensitive. It was concluded that haematuria is a frequent finding in the assessment of BPH patients and that additional tests should only be performed if indicated (e. in the case of abnormal urine cytology).003). However. Although the presence of diverticula was related to age. detrusor instability and low compliance. the presence of stones in the bladder indicates an abnormality in the bladder-emptying mechanism and is usually preceded by the presence of residual urine or recurrent urinary tract infections. while being missed on a renal ultrasound. particularly as most patients with bladder stones will have microscopic haematuria that will have been detected during the standard basic evaluation. Equally poorly documented is the impact that the presence or absence of bladder diverticula might have on outcome after prostate surgery. Homma et al. There was no correlation between any clinical parameter and the finding of microscopic haematuria. IVP. Instead. (11) evaluated urethroscopic findings and the results of urodynamic studies in 492 elderly men with LUTS. For example. They noted a clear correlation between cystoscopic appearance (grade of trabeculation and grade of urethral obstruction) and urodynamic indices.9 Intravesical pathology The detection of other pathology (urethral or intravesical) is advantageous and can be accomplished by endoscopy better than with most other modalities. Only three patients had a bladder tumour while 49 had urinary calculi. at detecting large bladder diverticula. the bladder neck to verumontanum distance and the cystoscopic appearance of occlusion did not correlate significantly (p > 0. or by destroying them with endoscopic instruments prior to washing them out. cystoscopy or transabdominal sonography for evaluating large bladder diverticula. 3. the presence of a large bladder diverticulum might dictate the type of intervention. there is also no doubt that bladder stones are detected equally well by IVP or by the non-invasive method of transabdominal sonography.11. The crux of the matter has to be whether or not the detection of bladder stones dictates the surgical procedure of choice. the majority of all bladder stones are rather small. In fact. 3.g. stones composed of poorly radio-opaque or radiolucent material are seen very well by transabdominal sonography. (13). (10) showed that patients had a high likelihood of outlet obstruction when their prostate size was greater than 30 mL or if their posterior urethra was severely obstructed on endoscopy. It is. anatomical or neurogenic nature. However. 26 UPDATE MARCH 2004 .11. While the cystoscopically estimated weight correlated with the presence of trabeculation (p = 0. 3. evident that other diagnostic modalities. At present. While it is not always clear whether the obstruction is of an organic. It should be noted. or more sensitive. It is therefore questionable whether or not urethrocystoscopy should be performed to assess the presence or absence of bladder stones prior to surgery for BPH. No data are available to document the sensitivity or specificity of cystography. however. urinalysis and a cystoscopy were performed in 750 consecutive patients with BPH. upper tract dilation. while approximately 8% of patients have no obstruction at all even if severe trabeculation is present. and can be removed during TURP through the sheath of the resectoscope. there was no relationship with bladder capacity. that bladder outlet obstruction is present in approximately 15% of patients with normal cystoscopic findings. 3.5 Relationship between trabeculation and prostate size Anderson and Nordling (9) examined the correlation between cystoscopic findings and the presence of trabeculation. It is obvious that the presence of a large bladder stone should guide the surgeon towards an open procedure rather than a lengthy electrohydraulic lithotripsy.11. They believe that the value of urethrocystoscopy is limited and advise against its use in the diagnosis of bladder outlet obstruction. however. it should be used primarily to exclude bladder pathology and to decide between interventional approaches. increasing amounts of residual urine and bladder instability. In a study by Ezz El Din et al. intravenous pyelography (IVP) or transabdominal sonography. suggesting the inadvisability of drawing the same conclusion in all patients.3.11.
nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=2448939& dopt=Abstract Barry MJ.61:392-394. Sihelnik SA.14:23-27.ncbi.ncbi.isismedical. Clinical Neurourol 1991. 1996. Correlations between clinical findings and urinary flow rate in benign prostatic hypertrophy.ncbi. Susset JG.nih.ncbi.ncbi.nlm. Elhilali MM. Debruyne FM.150:351-358.427-443. UPDATE MARCH 2004 27 . The correlation between urodynamic and cystoscopic findings in elderly men with voiding complaints. 8.5:61-66.fcgi?cmd=Retrieve&db=PubMed&list_uids=7693606& dopt=Abstract 2.nlm. 4. http://www. Dorflinger T. McConnell JD. http://www. Eri LM. http://www.nlm. II. http://www. Krane RJ. Bruskewitz RC.gov/entrez/query. 10.gov/entrez/query.25:243-247. Dutartre D.gov/entrez/query.ncbi. Lundhus E. Int Surg 1976. 91-104.com/ Larsen EH. de la Rosette JJ. 3. 5. http://www.nih. Benign prostatic hyperplasia. http://www. http://www.nih.3. pp.ncbi.gov/entrez/query. Rosier PF. Grayhack JT. Siroky B eds. 9. Urodynamic evaluation of male outflow obstruction.nih. cystometric and urodynamic findings.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=8583551& dopt=Abstract Quirinia A. In: Textbook of Benign Prostatic Hyperplasia. eds.ncbi. http://www.10 CONCLUSIONS Diagnostic endoscopy of the lower urinary tract should be considered an optional test for the following reasons: • the outcomes of the intervention are unknown • the benefits do not outweigh the harm of the invasive study • patients' preferences are expected to be divided. Int J Urol 1998. Norgaard JP. Bladder diverticula in patients with prostatism. Holtgrewe HL. Kirby R et al.gov/entrez/query.nih. Scand J Urol Nephrol Suppl 1995.gov/entrez/query.172:95-98. http://www. Nordling J.nlm.ncbi.11. Prostatism.70(Suppl 1): 275-279.fcgi?cmd=Retrieve&db=PubMed&list_uids=8578262& dopt=Abstract Shoukry I.nlm. Role of uroflowmetry in the assessment of lower urinary tract obstruction in adult males. Oxford: Isis Medical Media. Kawabe K. Gotoh M.nih.15:355-358. Winfield HN.gov/entrez/query. Cockett AT. J Urol 1993. Takei M. J Urol 1996.gov/entrez/query.11.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7375838& dopt=Abstract Homma Y. Hoffmann AL. Urol Res 1987.155:1018-1022. 11. The correlation between cysto-urethroscopic. Pathology of benign prostatic hyperplasia. Complications of invasive.gov/entrez/query.47:559-566.nlm.nih. 3. Jorgensen HS. urodynamic examinations and prostate biopsies in patients with benign prostatic hyperplasia.nlm. Predictability of conventional tests for the assessment of bladder outlet obstruction in benign prostatic hyperplasia. Int Urol Nephrol 1993.fcgi?cmd=Retrieve&db=PubMed&list_uids=61184& dopt=Abstract Simonsen O.nih. Yamaguchi T.fcgi?cmd=Retrieve&db=PubMed&list_uids=1376196& dopt=Abstract Bostwick DG.ncbi. Scand J Urol Nephrol 1980. Berge V.fcgi?cmd=Retrieve&db=PubMed&list_uids=7686980& dopt=Abstract Andersen JT. de Wildt MJ. Moller-Madsen B. Tveter KJ. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=9535603& dopt=Abstract El Din KE. Cancer 1992. 12.11 REFERENCES 1. The significance of age on symptoms and urodynamic and cystoscopic findings in benign prostatic hypertrophy.nlm. Br J Urol 1975.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1191927& dopt=Abstract Anikwe RM. 6. Wijkstra H.nlm. 7. http://www. The scope of the problem. Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia.
nlm. Eur Urol 1996. Pressure-flow studies should be considered for patients prior to surgical treatment in the following subgroups: • younger men (e. 6. However. 2. the use of I-PSS is recommended because of its worldwide distribution and use. Urinalysis may be included in the primary evaluation. However. Imaging of the upper urinary tract is recommended in patients with LUTS and one of the following: • History of. < 50 years of age) • elderly patients (i. > 80 years of age) • post-void residual urine volume over 300 mL • Qmax more than 15 mL/s • suspicion of neurogenic bladder dysfunction • after radical pelvic surgery • previous unsuccessful invasive treatment. RECOMMENDATIONS FOR ASSESSMENT Among all the different urinary symptom score systems currently available. 3. Ultrasound of the bladder.g.30:409-413. ultrasonography is the method of choice. or a current.13. Ezz el Din K. Debruyne FM. Prostate size should be assessed when considering open prostatectomy and TUIP. 15. 10. The predictive value of microscopic haematuria in patients with lower urinary tract symptoms and benign prostatic hyperplasia. imaging of the prostate by transabdominal ultrasound and TRUS is optional. Uroflowmetry is recommended as a diagnostic assessment in the work-up of patients with LUTS and is an obligatory test prior to surgical intervention. If the voided volume is less than 150 mL or Qmax is greater than 10 mL/s. 12. urinary tract infection • History of urolithiasis • History of urinary tract surgery • History of urothelial tumour (including IVU) • Haematuria (including IVU) • Urinary retention. 11. Measurement of residual urine volume is a recommended test in the assessment of patients with LUTS suggestive of benign prostatic obstruction. Routine imaging of the urethra is not recommended in the diagnostic work-up of patients with LUTS. Post-void residual urine measurement is recommended during initial assessment. preferably via the transrectal route. There is a consensus that if imaging of the upper urinary tract is performed. and prior to finasteride therapy. is a valuable diagnostic tool for the detection of bladder diverticula or bladder stones. the minimal requirement is to assess the upper urinary tract function with a creatinine measurement and/or an ultrasonographic examination. Endoscopy is recommended as a guideline at the time of surgical treatment to rule out other pathology and to assess the shape and size of the prostate.fcgi?cmd=Retrieve&db=PubMed&list_uids=8977059& dopt=Abstract 3. 9. 28 UPDATE MARCH 2004 .e. In straightforward cases presenting for the first time with LUTS. pressure-flow studies remain optional tests.12 1. 7. 5. DRE is a minimal requirement in patients undergoing investigation for LUTS. 8. however. http://www. particularly in elderly men. 16. it should be noted that there is little evidence in the literature to support this conclusion. Koch WF.gov/entrez/query. The method of choice for the determination of prostate volume is ultrasonography.ncbi.nih. de Wildt MJ. which may have an impact on the treatment modality chosen. 14. Routine imaging of the urinary bladder cannot be recommended as a diagnostic test in the work-up of patients with LUTS. pressure-flow studies should be considered before surgical intervention. de la Rosette JJ. 4. CT and MRI currently have no place in the routine imaging of the upper urinary tract in elderly men with LUTS. 13. In patients undergoing investigation for LUTS.
periodic monitoring and lifestyle advice. perineal pressure and mental ‘tricks’ to take the mind off the bladder and toilet in the control of irritative symptoms. 4.1 TREATMENT Watchful waiting Many men with LUTS do not complain of high levels of bother and so are suitable for non-medical non-surgical management . reassurance and periodic monitoring Although there is little high quality evidence to support this (the studies have not been done) it seems rational to provide the following for men who are candidates for WW: • prostate. if left untreated. It is however not possible to guarantee against early undetectable prostate cancer. 4. Approximately 85% of men will be stable on WW at 1 year. this may focus their attention on specific symptoms and reinforce their fear.3 Lifestyle advice Optimization of WW can be achieved with lifestyle modifications.1.4. deteriorating progressively to 65% at 5 years (5. 4. such as penile squeeze. A large study comparing WW and TURP in men with moderate symptoms showed that those who had surgery had improved bladder function over the WW group (flow rates and post void residual volumes) with the best results being in those with high levels of bother. • avoidance or moderation of caffeine and alcohol which may have a diuretic and irritant effect. urgency and nocturia. • reviewing a man’s medication and optimising the time of administration or substituting drugs for others that have fewer urinary effects. Anxiety regarding prostate cancer can be the principal reason why a man consults his doctor about his urinary symptoms. At least three high-quality studies have shown that men with LUTS are at no greater risk of prostate cancer than asymptomatic men of the same age (7-9). breathing exercises. Minor changes in lifestyle and behaviour can have a beneficial effect on symptoms and may prevent deterioration requiring medical or surgical treatment. general practitioner or specialist nurse. If these men harbour an anxiety about prostate cancer. Men with mild to moderate uncomplicated LUTS (causing no serious health threat) who are not too bothered by their symptoms are suitable for a trial of WW.2). In many men it is regarded as the first tier in the therapeutic cascade and therefore the majority of men will be offered watchful waiting at some point. • urethral stripping to prevent postmicturition dribble. BPH and LUTS education with the help of written information • reassurance that LUTS does not progress in everyone. UPDATE MARCH 2004 29 . reassurance. flow rates and post-void residual volume measurements are useful in determining whether a patient’s condition has deteriorated. WW is a viable option to many men as few. • use of relaxed and double-voiding techniques. The recommended total daily fluid intake of 1500 mL should not be reduced. will progress to acute urinary retention and complications such as renal insufficiency and stones (1. Similarly some men’s symptoms may improve spontaneously whilst others remain stable for many years (3).1.a policy of care that has been called watchful waiting (WW). men should be periodically seen by either a urologist. 4.6).2 Education. Symptom scores. • distraction techniques. Lifestyle advice should include: • reduction of fluid intake at specific times aimed at reducing urinary frequency when most inconvenient. Most men over 50 will note changes in their urinary function with or without high levels of bother. • WW does not imply no activity. for example at night or when going out in public. • providing necessary assistance when there is impairment of dexterity. 36% crossed over to surgery in 5 years leaving 64% doing well in the WW group (4). symptom bothersomeness. • bladder re-training. • information about prostate cancer is nearly always required. It is customary for this type of management to include the following components: education.1 Patient selection All men with LUTS should be formally assessed prior to starting any form of management in order to identify those with complications that may benefit from intervention therapy. Reassurance that serious complications are unlikely to occur. mobility or mental state. by which men are encouraged to ‘hold on’ when they have sensory urgency to increase their bladder capacity (to around 400 mL) and the time between voids. thereby increasing fluid output and enhancing frequency. The reason why some men deteriorate with WW and others do not is not well understood.1. increasing symptom bothersomeness and post-void residual volumes appeared to be strongest predictors of failure.
1 Efficacy and clinical endpoints Today.nlm. 5.2. Reda DJ. http://www.1. Reda DJ. American Cancer Society National Prostate Cancer Detection Project. 5-year outcome of surgical resection and watchful waiting for men with moderately symptomatic BPH: a department of Veterans Affairs cooperative study. 2.nih. Reassurance. 4.2 Medical treatment 4.160:12-16. 30 UPDATE MARCH 2004 .nih. Cancer 1996.gov/entrez/query. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=8630923& dopt=Abstract Rietenberg JBW. Further research in this area is required.ncbi.gov/entrez/query.gov/entrez/query.nih. 8.nih. J Urol 1998. Babaian RJ. J Urol 1997.77:150-159. Evaluation of patients with bladder outlet obstruction and mild international prostate symptom score followed up by watchful waiting. Prostate 1990. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=1689166& dopt=Abstract Flanigan RC.6 mL/s (1-4). Dalkin BL et al. http://www.1. D’Ancona CA. J Urol 1994. Richie JP.fcgi?cmd=Retrieve&db=PubMed&list_uids=7527493& dopt=Abstract Netto NR Jr. periodic monitoring and lifestyle modifications can be used to optimise WW.fcgi?cmd=Retrieve&db=PubMed&list_uids=9628595& dopt=Abstract Wasson JH. 3. Boeken Kruger AE et al.1.15:1283-1290. 4. after the completion of many trials.1.3(Suppl):1-7. Urol 1999. http://www. 9. Bruskewitz RC. 5-alpha reductase inhibitor) 4. Ratliff TL. Abrams PH.ncbi.630 men.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933046& dopt=Abstract Catalona WJ. Additional value of the AUA 7 symptoms score in prostate cancer (PC) detection.nlm.ncbi. New Engl J Med 1995.ncbi.2.nlm.gov/entrez/query.ncbi.3-1. Feneley RC. http://www. Ahmann FR.1.gov/entrez/query. Wasson JH Anderson RJ.nlm. Br J Urol 1981.53:613-616. REFERENCES Ball AJ. The natural history of benign prostatic hyperplasia: what have we learned in the last decade? Urology 2000. Murphy GP. Kavoussi LR. The results of a five-year early prostate cancer detection intervention. The natural history of untreated ‘prostatism’. Elinson J. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=6172172& dopt=Abstract Kirby RS.4 CONCLUSIONS Men with mild to moderate LUTS with low levels of bother are suitable for WW. Flanigan RC.gov/entrez/query. the efficacy of 5-alpha reductase inhibitors is unquestionable and has been demonstrated over large clinical trials.56:3-6. 4.nlm. Kranse R. http://www.1 Finasteride (type 2. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. It can reduce the size of the prostate gland by 20-30%.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=11074195& dopt=Abstract Isaacs JT. deKernion JB.2. http://www.5 1.nlm.• treatment of constipation.nlm. Hudson MA.fcgi?cmd=Retrieve&db=PubMed&list_uids=7512659& dopt=Abstract Mettlin C.nih.gov/entrez/query.gov/entrez/query. it improves symptom scores by approximately 15% and can also cause a moderate improvement in the urinary flow rate of 1. Research in this area is required so that lifestyle advice to men with LUTS can be refined.157:467.1 5-alpha reductase inhibitors 4. Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. 7. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate.332:75-79. Scardino PT. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicentre clinical trial of 6.nlm.nih.ncbi. Again it must be stated that there is little high-quality evidence that provides reliable information on any of these lifestyle activities.nih. Netto MR. Keller AM. Bruskewitz RC. 6.nih.ncbi. de Lima ML. Henderson WG.53:314-316.
impotence (8. It has been agreed that 12 months of finasteride. Two major studies (21. A recent North American study has also verified that long term (10 year) treatment is well tolerated and results in durable symptom relief (13). In another report. In the PLESS study the side effects reported were decreased libido (6. The fourth compared dutasteride with finasteride for one year which showed that drug related adverse events were similar for both compounds. Such side-effects are considered ‘minimal’ since they did not increase over time and did not cause many patients to discontinue their treatment.22) verified earlier reports.2. in 4.1. In a recently published study it was also shown that dutasteride UPDATE MARCH 2004 31 . Finally it has also been shown that the four year inhibition of type 2 5alpha-reductase with finasteride does not adversely affect bone mineral density (20). double-blind clinical trials have been presented (28.7%) and in less than 1% of the patients other disorders such as rash. reduces serum PSA levels by 50%. so that the ratio of free PSA to total PSA remained unchanged (24).040 men. activity interference and worry due to urinary symptoms.1. and has shown that this improvement could be maintained for at least 6 years (12). 4.A meta-analysis of six randomized clinical trials showed that baseline prostate volume was a key predictor of various treatment outcomes and that finasteride was more effective in prostates larger than 40 mL (5). multicentre. All these figures were higher than those observed for placebo. 4. Various studies have confirmed this alternative for patients with haematuria due to BPH who. 4. at the same time. Various trials have concluded that finasteride significantly reduced acute urinary retention and the need for surgical treatment in men with BPH (6-8). the question of whether or not it masks the early detection of localized prostatic adenocarcinomas has been raised. placebo-controlled finasteride trials.2 Dutasteride It is known that finasteride suppresses dihydrotestosterone (DHT) by about 70% in the serum and by 90% in the prostate.1. showed that patients with larger prostate volumes or higher PSA levels have an increased risk of developing acute urinary retention and therefore derive the greatest benefit from finasteride therapy (10).29).4 Effect on PSA It is known that finasteride lowers serum PSA levels. A phase II study including 399 patients showed that dutasteride can cause greater suppression of DHT than finasteride (27). had no significant obstruction or adenocarcinoma of the prostate (14-17).2. 5 mg/day. In a major placebo controlled trial including 3.1.2. the percentage of free PSA did not change significantly (25). In a recent publication from the PLESS study group it was shown that the finasteride-related sexual adverse experiences occurred mainly during the first year of therapy (18). Three of these studies were placebo controlled studies and they showed that dutasteride can reduce prostatic volume by almost 26%. the Scandinavian Finasteride Study Group has verified an earlier observation that the maximum efficacy of finasteride action is obtained after 6 months.1.4%).4 ng/mL.2 Haematuria and finasteride Another important benefit of finasteride in common clinical urological practice is that it can be used to treat haematuria associated with BPH. or enlarged prostate glands. could predict the best long-term response to finasteride (9). In one paper. 4.3 Side-effects These are mainly related to sexual function. In addition. The North American Finasteride Study Group reported that patients treated with finasteride maintained a reduction of prostate volume and an improvement in symptom score and maximal urinary flow rate over a period of 5 years (11). Pooled data from the patients enrolled in all four studies proved that dutasteride is well tolerated and adverse events included erectile dysfunction. that finasteride did not cause problems in the diagnosis of cancer from needle specimens as cancer tissue remained unaltered (23).222 men. Another conclusion from the PLESS study was that in both older and younger men with symptomatic BPH.1. ejaculatory disorders and gynecomastia (28).2. Dutasteride is a new drug that has the ability to suppress both type 1 and type 2 isoenzymes and as a consequence serum DHT decreases by about 90% (26). finasteride-treated patients had significantly less bother. The results of papers dealing with the impact of finasteride on free PSA level are confusing. The remaining DHT is the result of type 1 5-alpha reductase activity. improve symptoms and urinary flow rate and reduces also the incidence of acute urinary retention and BPH related surgery. Data from three multinational. It was also shown. finasteride seemed to lower total and free PSA levels equally. decreased ejaculate (3. The long-term effects of finasteride have also been examined.1.1%). Baseline PSA levels of 1. breast enlargement and breast tenderness (9). finasteride had the same safety profile and no drug interactions of clinical importance were observed (19). Thus. and concluded that doubling the PSA level allowed appropriate interpretation of PSA values and that finasteride treatment did not mask the detection of prostatic adenocarcinomas. at the histopathological level. The results of four large randomized.
et al. Walsh PC. Urology 2002. The follow-up period of the MTOPS trial was 4.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7495111&query_hl=2&itool=pubmed_docsum Gormley GJ. [Symptom Management After Reducing Therapy].5 years and another conclusion drawn from this study was that finasteride needs time to reveal its beneficial therapeutic capacity.nih.ncbi. • The long-term (up to 10 years) effects of 5.fcgi?cmd=Retrieve&db=PubMed&list_uids=8911291& dopt=Abstract Vaughan D.fcgi?cmd=Retrieve&db=PubMed&list_uids=12475666& dopt=Abstract 2. Andersen JT.gov/entrez/query. 4. in increasing median maximal flow rates.nlm. Elhilali MM. Sullivan M. In another study examining combination therapy. Long-term (7 to 8-year) experience with finasteride in men with benign prostatic hyperplasia. Efficacy and safety of finasteride therapy for benign prostatic hyperplasia: results of a 2-year randomised controlled trial (the PROSPECT Study). Geller J. have shown that the combination of finasteride to doxazocin was beneficial (33).2. • The combination of a 5-alpha reductase inhibitor with an alpha-blocker seems beneficial according to the data currently available.2. 4.nih. Can finasteride reverse the progress of benign prostatic hyperplasia? A two year placebo-controlled study. Cook T. http://www.The combination therapy was superior to either drug alone in reducing AUA symptom scores. Fradet Y. Wolf H. placebo-controlled clinical trials that 5-alpha reductase inhibitors are capable of reducing prostate volume and improving symptom scores and flow rates.2. McConnell J. 4.1. Pommerville PJ. McConnell JD. Perreault JP. By doubling PSA serum levels.ncbi.nlm.32). Kontturi M. Lehtonen T. Daurio C. • Side-effects of 5-alpha reductase inhibitors are minimal • Treatment with 5-alpha reductase inhibitors does not mask the detection of prostate carcinoma. • Men with small prostates (< 40 mL) are less likely to benefit from finasteride. Afridi SK. The lack of finasteride efficacy in these two trials may be due to smaller baseline prostate volumes. http://www. • 5-alpha reductase inhibitors can alter the natural history of symptomatic BPH by influencing prostatectomy and acute urinary retention rates. Imperato-McGinley J.155:1251-1259. Roy J. Pappas F. http://www.60:1040-104. Can Med Assoc J 1996.nih. The Finasteride Study Group.nih. A multicentre.ncbi. 3.3 Combination therapy The combination of finasteride with an alpha-blocker was examined earlier in two clinical trials (31.gov/entrez/query. N Engl J Med 1992.327:1185-1191. Stoner E. Bracken BR. Beisland HO. Matsumoto AM. Bruskewitz RC. Recently the results of a multicentre randomized. however. Ekman P.gov/entrez/query. it was shown that patients with lower urinary tract symptoms and moderately enlarged prostates initially receiving combination therapy with finasteride and an alpha-blocker were likely to experience no significant symptom deterioration after discontinuing the alphablocker following 9 to 12 months of combination therapy (34). an accurate estimation can be expected. Dutasteride shows similar efficacy and tolerability as finasteride in suppressing both type 1 and type 2 isoenzymes but further randomized studies are needed. The costs of such protocols.1. Maximum benefits are seen at a mean period after 6 months.4 CONCLUSIONS • It has been shown in numerous randomized.nlm.gov/entrez/query.nlm.46:631-637.ncbi.5 REFERENCES 1. should be further evaluated. Waldstreicher J.fcgi?cmd=Retrieve&db=PubMed&list_uids=1383816& dopt=Abstract Nickel JC. Boake RC. Stoner E. Urology 1995. on the short term combination of dutasteride and tamsulosin involving 327 patients confirmed compatible results (35). placebo-controlled study (SMART study). The Scandinavian BPH study group. The effect of finasteride in men with benign prostatic hyperplasia.1. No additional benefit from combining these two drugs was observed in either study. 32 UPDATE MARCH 2004 . Bracken B. Johansson JE. Tenover JS.alpha reductase inhibitors are substantial. Andriole GL. http://www. 4. Tveter K. placebo-controlled double-blinded trial (MTOPS trial). Meeha A. and in reducing the likelihood of acute urinary retention and surgery. Imperato-McGinley J.is associated with clinically significant improvement in BPH specific health status as measured by the BPH Impact Index (BII) (30).
nih. Ko A. PLESS Study Group. Wang D. Girman CJ.38:563-568. Marshall VR. Proscar Long-term Efficacy and Safety Study.nih. Pappas F. Nickel JC. Roehrborn CG.nlm. The North American Finasteride Study Group. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Wedderburn AW.164:1670-1671.ncbi.48:398-405. Walsh P.nlm. http://www.37:528-536.5.nih.ncbi. Characterization of patients and ultimate outcomes. N Engl J Med 1998. Urology 1999.ncbi.nih.4:670-678.ncbi. Basketter V.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=10765090& dopt=Abstract Bruskewitz R.fcgi?cmd=Retrieve&db=PubMed&list_uids=10197842& dopt=Abstract Ekman P.D. Taylor A. Urology 1999. http://www. Long-term treatment with finasteride in men with symptomatic benign prostatic hyperplasia: 10-year follow-up. A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride. Waldstreicher J. Lieber MM. 13. Bruskewitz RC.gov/entrez/query. Maximum efficacy of finasteride is obtained within 6 months and maintained over 6 years. Boyle P. Roy JB. Kashif KM. http://www. 9. Perreault JP. Kozlowski D. 10.A. Holmes SA.gov/entrez/query. Albertsen P. Malice MP. 12. UPDATE MARCH 2004 33 . Wedderburn AW. Nickel GC. Soloman LZ. Bracken R.nlm. Kantor S. Kashif KM. Narayan P. Boyle P.gov/entrez/query. Prostate volume and serum prostate-specific antigen as predictors of acute urinary retention.fcgi?cmd=Retrieve&db=PubMed&list_uids=9555559& dopt=Abstract Lam JS. Trachtenberg J. Rigby O. Nickel JC. Combined experience from three large multinational placebo-controlled trials. Urology 1996. Bruskewitz R. Urinary retention in patients with BPH treated with finasteride or placebo over 4 years. Herlihy R.nih. Bruskewitz R. Patterson L.L. Boake R. Brown BT.fcgi?cmd=Retrieve&db=PubMed&list_uids=12597947& dopt=Abstract Foley SJ. 11. Efficacy of finasteride is maintained in patients with benign prostatic hyperplasia treated for 5 years.nih. Norman R. Romas NA. Glickman S.nih.Effect of finasteride on bother and other healthrelated quality of life aspects associated with benign prostatic hyperplasia.Z. Schulman CC.nlm.nlm. Fusilier H. 6. Waldstreicher J. Kornitzer G.B. Stoner E. A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride.nih. Lowe FC. 15.gov/entrez/query.nih.ncbi. Eur Urology 2000. Eur Urol 2000. http://www. Summerton D. Malek GH. Finasteride Long-term Efficacy and Safety Study Group. Andersen JT. Roehrborn CG. Kandzari S. Holmes SA.fcgi?cmd=Retrieve&db=PubMed&list_uids=11096237& dopt=Abstract Hudson PB. http://www.ncbi. Eur Urol 1998. Follow-up of the Scandinavian Open-extension Study. Gabriel M. Meehan A. Cox C. Finasteride significantly reduces acute urinary retention and need for surgery in patients with sympomatic benign prostatic hyperplasia.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9187688& dopt=Abstract McConnell JD. Holtgrewe HL.gov/entrez/query. Gould AL.nlm. Prostate volume predicts the outcome of treatment of benign prostatic hyperplasia with finasteride: meta-analysis of randomized clinical trials. Summerton D.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10647664& dopt=Abstract Foley SJ. http://www. Sullivan M. Wang D. Basketter V.fcgi?cmd=Retrieve&db=PubMed&list_uids=10510926& dopt=Abstract Marberger MJ. Jacobsen CA.gov/entrez/query.nlm.nlm.49:839-845. Andriole G.fcgi?cmd=Retrieve&db=PubMed&list_uids=9475762& dopt=Abstract Roehrborn CG. 8. J Urol 2000.61:354-8. The PLESS Study Group.ncbi. Waldstreicher J. Taylor AM. J Urol 2000.ncbi. Wang DZ.nlm. Soloman LZ.fcgi?cmd=Retrieve&db=PubMed&list_uids=8804493& dopt=Abstract Andersen JT.gov/entrez/query.53:690-695.ncbi.ncbi. Urology 1997.33:312-317.163:496-498.338:557-563. The Scandinavian Finasteride Study Group. Urology 2003. 14.F. Rosenblatt S. Elhilali M. Holtgrewe HL. Nickel JC. Fowler J. Romas NA. Waldstreicher J.nih. 7. Johnson E. http://www. Stoner E. Geller J. http://www. Lieber M. http://www.gov/entrez/query. Anderson R. http://www.
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Harkaway RC.1 Uroselectivity Alpha-blockers were first introduced into clinical practice for the treatment of LUTS secondary to BPH in 1978. alpha1adrenoceptors were identified and selective. Baldwin KC. Taylor S.nlm. Benign Prostatic Hyperplasia Study Group. Alpha-blocker therapy can be withdrawn in the majority of men following initial combination therapy with the dual 5alphareductase inhibitor dutasteride. was investigated.167:265.44:461-466. Hofner K. http://www.nih. abstract 1042. Clarke R. 32.gov/entrez/query. following experimental work demonstrating the predominance of adrenoceptors in human prostate smooth muscle (1).ncbi. The long term effects of medical therapy on the progression of BPH: Results from the MTOPS trial. finasteride. 29.nih.2. Initially. doxazosin. Guimaraes M. http://www. van Vierssen Trip OB. prospective. due to its unselective nature.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract& list_uids=14499682 4. Morril B. ARIA3002 and ARIA3003 study investigators.fcgi?cmd=Retrieve&db=PubMed&list_uids=12814679& dopt=Abstract O’Leary MP. Jacobi G. Subsequently. Roehrborn CG.nlm.nlm. Nickel C. placebo-controlled clinical studies. finasteride and the combination of both in the treatment of BPH. Narayan P.fcgi?cmd=Retrieve&db=PubMed&list_uids=8684407& dopt=Abstract Debruyne FM.335:533-539. http://www. Padley RJ. http://www. Hoefner K.nlm. Resel L. European ALFIN Study Group. Wilson T.fcgi?cmd=Retrieve&db=PubMed&list_uids=12887480& dopt=Abstract Lepor H. 35. Gabriel H.34:169-175. alfuzosin. alpha-blockers were developed. Jardin A.ncbi. Machi M. a novel.nih. the sideeffect profile. Boyle PJ. Haakenson C. However. Dixon CM. J Urol 2002. the novel dual 5 alpha-reductase inhibitor.fcgi?cmd=Retrieve&db=PubMed&list_uids=9732187& dopt=Abstract Mc Connell JD. Williford WO. Brawer MK. Gormley G. N Engl J Med 1996. dual 5-alpha reductase inhibitor. http://www. Ginsberg PC.gov/entrez/query. In view of the very real placebo effect seen in the treatment of patients with LUTS secondary to BPH. prazosin. Discontinuation of alpha-blockade after initial treatment with finasteride and doxazosin in men with lower urinary tract symptoms and clinical evidence of benign prostatic hyperplasia. A large number of alpha1-selective. this review will focus on the results of randomized.gov/entrez/query.161:1037. Hermann D.ncbi. 31.gov/entrez/query. better-tolerated. Nickel C. UPDATE MARCH 2004 35 . 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=12350480& dopt=Abstract Andriole GL. Barry MJ. McCarthy C.nih.nlm. BJU Inter 2003. indoramin.nih. Eur Urol 2003. Eur Urol 2003. Veterans Affairs Cooperative Studies. Andriole G. was unacceptable to patients (2. Hobbs S.ncbi. 30.nih.2 Alpha-blockers Over the past 10 years.fcgi?cmd=Retrieve&db=PubMed&list_uids=11489700& dopt=Abstract Barkin J. Witjes WP. Urology 2001.nlm.gov/entrez/query. Sustained-release alfuzosin. Efficacy and safety of a dual inhibitor or 5-alphareductase types 1 and 2 (dutasteride) in men with benign prostatic hyperplasia.58:203-209. they all have a similar efficacy and side-effect profile.gov/entrez/query. Roehrborn C. 33.ncbi. Pushkar D. Kirby R Safety and tolerability of the Dual 5 alpha-Reductase Inhibitor dutasteride in the treatment of benign prostatic hyperplasia. Geffriaud-Ricouard C. the prescribing of alpha-blockers has steadily increased. J Urol 1999. http://www.gov/entrez/query. terazosin). or both in benign prostatic hyperplasia. alpha-blockers are available (tamsulosin.nih.ncbi. Improvements in benign prostatic hyperplasia-specific quality of life with dutasteride. Effective suppression of dihydrotestosterone (DHT) by GI 198745. Eur Urol 1998.ncbi. phenoxybenzamine. Andriole GL. Boyle P. The efficacy of terazosin. the non-selective alpha-blocker.nlm. Colloi D. 28. Roehrborn CG. 34. http://www. On behalf of the ARIA3001. This increase has been driven partly by patients wishing to achieve symptomatic relief without undergoing surgical treatments and partly by the marketing of these drugs by pharmaceutical companies.44:82-88.2.60:434-441. Urology 2002. Delauche-Cavallier MC.3). Broadly speaking.27.92:262-265.2.
although flow rates do improve with these agents relative to placebo. irrespective of whether symptoms were moderate or severe.2. Long-term studies tend to be open-label extensions or increasingly ‘real life practice’ studies which do not conform to an experimental design.3 Pharmacokinetics Alpha-blockers are taken orally and the dosage depends on the half-life of the relevant drug. Symptoms can improve within 48 hours. terazosin and doxazosin have the advantage of being long-acting.2.6 Durability Good data on long-term efficacy and the effect on natural history are currently not available. Nevertheless. One-third of men will not experience significant symptom reduction. 4. Currently there is no method of predicting which men will show a response (4). The various types of alpha-blockers cannot be distinguished by their ability to relieve symptoms or improve flow. Because of this. 36 UPDATE MARCH 2004 . asthenia. postural hypotension.2 Mechanism of action Alpha-blockers are thought to act by reducing the dynamic element of prostatic obstruction by antagonizing the adrenergic receptors responsible for smooth muscle tone within the prostate and bladder neck. once-daily preparations. None of these trials continued therapy beyond the period of catheterization. The optimal duration of the trial of therapy has been debated.7 Adverse effects The most commonly reported side-effects with alpha-blocker therapy are headaches.2. the exact contributions of alpha1-receptor subtypes and the potential central effects in vivo remain unclear. without catheter. Studies have concentrated on two important reasons. compared with placebo (6). nasal congestion and retrograde ejaculation (6). In general. There is no justification in prolonging therapy beyond one month in men who do not respond. However.2. An I-PSS assessment requires at least one month of therapy. Whether this translates into a reduction in clinical side-effects remains to be seen. 4. As a result. There is no evidence that efficacy diminishes with time.6 per month. This is implied from in-vitro experiments and the predominant distribution of alpha1-receptors within the prostate and bladder neck.2. Predicting response for any individual is more difficult and therefore a trial of therapy is required. namely.4 Assessment It is not unreasonable to offer a trial of alpha-blockers to all men with uncomplicated LUTS.2.5 Clinical efficacy The interpretation of existing literature regarding the efficacy of alpha-blocker therapy is clouded by the wide discrepancy in methodology and reporting of clinical studies. 4. Djavan and Marberger’s meta-analysis estimated that overall symptoms improved by 30-40% and that flow rates improved by 16-25%. Patients may choose to stop taking medication for a number of reasons.2. 4.2. Tamsulosin. Two trials have looked at alfuzosin (11). and one at terazosin (12).2.2.01 and 1. In general. following an episode of acute urinary retention.8 Acute urinary retention Early trials comparing alpha-blockers to placebo showed an increased likelihood of a successful trial. 22.214.171.124. Tamsulosin resulted in less orthostatic hypotension than alfuzosin under test conditions. Urodynamic studies measuring voiding pressures do not reveal any significant relief of obstruction.2. secondary publications that have compared outcomes between these studies have been useful (5-7). the symptom status of men did not predict whether they were likely to stop therapy. alfuzosin. Studies are underway which address the question of whether men do benefit from alpha-blockade in the six months following acute urinary retention. The effect seems to be independent of the type of alpha-blocker studied. dizziness.2. the occurrence of adverse effects and lack of efficacy (8). in this context these types of design are informative. drowsiness. 4. the rate of sideeffects in studies looking at tamsulosin and alfuzosin were equivalent to placebo (4-10%). Most men experience re-retention within the first two months (13). a large number of urologists have adopted this practice. Drop-outs occurred at the same rate. The rate of drop-out in men on alpha-blockers appears to be between 0.
nlm. McCarthy C. de la Rosette JJMCH.nlm. 4.51:901-906. Urology 1998. supportive data are weak. A placebo controlled double blind study of the effect of phenoxybenzamine in benign prostatic obstruction. Eur Urol 1999. http://www. http://www. • Long-term data are limited but suggest that the benefits of treatment are sustained. Long-term quality of life in patients with benign prostatic hypertrophy: preliminary results of a cohort survey of 7093 patients treated with alpha-1 adrenergic blocker. Lepor H. Meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. Br J Urol 1982.gov/entrez/query. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=88984& dopt=Abstract 3.ncbi. http://www. prostatic capsule and bladder neck. McCarthy C.fcgi?cmd=Retrieve&db=PubMed&list_uids=11074198& dopt=Abstract 8.nlm. Br J Urol 1975.nlm.24(Suppl 1):34-40. http://www. http://www. Raz S. double-blind extension of phase III trial.gov/entrez/query. 610-632. http://www.nlm. Proceedings of the Fourth International Consultation on BPH.fcgi?cmd=Retrieve&db=PubMed&list_uids=9609624& dopt=Abstract 10. Choa RG. • Patients should be informed about the side-effects of alpha-blocker therapy and the need for longterm use. 2000.36:1-13. Although the side-effect profiles for some drugs are reported to be more favourable. In: Denis L.nlm. Andersson KF. pp.nih.ncbi. Zeigler M. • There is no difference between different alpha-blockers in terms of efficacy.ncbi.2. Colloi D. Debruyne FM.50:551-554. Delauche-Cavallier MC. finasteride and the combination of both in the treatment of benign prostatic hyperplasia. Br J Urol 1978. Urology 1997. Long-term evaluation of tamsulosin in benign prostatic hyperplasia: placebo-controlled.4. Adrenergic and cholinergic receptors in the human prostate. http://www.9 CONCLUSIONS • Alpha-blocker therapy can result in a rapid improvement in symptoms by a factor of 20-50% and an improvement in the flow rate of 20-30%.49:197-205. Plymouth: Health Publications. QOL BPH Study Group in General Practice. Tamsulosin Investigator Group.fcgi?cmd=Retrieve&db=PubMed&list_uids=9732187& dopt=Abstract UPDATE MARCH 2004 37 .fcgi?cmd=Retrieve&db=PubMed&list_uids=1148621& dopt=Abstract 2.fcgi?cmd=Retrieve&db=PubMed&list_uids=6184106& dopt=Abstract 4. Review.nih. Meretyk S.gov/entrez/query. Debruyne FMJ. Caine M.2. Rosier PF.nlm.ncbi. Eur Urol 1993. Khoury S et al.47:193-202. These changes have been shown to be significant in randomized. Alpha blockers: are all created equal? Urology. July 1997.nih.nih.ncbi. Djavan B. Witjes WP.nih.gov/entrez/query.nih. Perlberg S. Caris CT. A stratified analysis.gov/entrez/query.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9037281& dopt=Abstract 5.nlm. Eur Urol 1998. Resel L.56(5 Suppl 1):20-2.nih. Bladder outflow obstruction treated with phenoxybenzamine. Griffiths K. Stone AR. α-blockers clinical results. Marberger M.ncbi. alfuzosin. Shah PJ.gov/entrez/query.nlm. Caine M. placebo-controlled studies. treatment should be discontinued. If a patient does not experience an improvement in symptoms after an 8-week trial.2.gov/entrez/query. 6.34:169-175. Paris. Sustained-release alfuzosin.ncbi. Chapple CR. Geffriaud-Ricouard C. http://www.ncbi. European ALFIN Study Group. Lukacs B. Witjes WP.gov/entrez/query.10 REFERENCES 1.nih. Jardin A.54:527-530. Urodynamic and clinical effects of terazosin in symptomatic patients with and without bladder outlet obstruction.gov/entrez/query. 1998.fcgi?cmd=Retrieve&db=PubMed&list_uids=10364649& dopt=Abstract 7. Grange JC. Abrams PH. Bono VA et al.ncbi. eds. Debruyne FMJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=7687557& dopt=Abstract 9.2.
fcgi?cmd=Retrieve&db=PubMed&list_uids=11750257& dopt=Abstract Debruyne F. http://www.ncbi.1 CONCLUSIONS The mode of action of phytotherapeutic agents is unknown. World J Urol 2002. 6.nih. Herbal medications in the treatment of benign prostatic hyperplasia (BPH). is also included to this chapter. Shearer MG. http://www.2. Eur Urol 2002.3. Teillac P.ncbi. 4. Mac Donald R. 4.gov/entrez/query. Chan LW.gov/entrez/query.ncbi.3 Phytotherapeutic agents The use of phytotherapy in treating lower urinary tract symptoms and benign prostatic hyperplasia has been popular in Europe for many years and has recently spread in the USA. http://www.gov/entrez/query.(1):CD001044. Comparison of a phytotherapeutic agent (Permixon) with an alphablocker (Tamsulosin) in the treatment of benign prostatic hyperplasia: a 1-year randomized international study.12:15-18. Rizvi S.nih. Mulrow C.nlm. http://www. Long term follow-up following presentation with first episode of acute urinary retention.nlm.11. Lau J. Mitchel I-D. Gallagher H. 3.ncbi. Transurethral vaporisation. Vela-Navarrete R. McNeill SA. 7.19:426-435. http://www.2 REFERENCES 1.163:307.nih. These agents are composed of various plant extracts and it is always difficult to identify which component has the major biological activity. Phytotherapy in the treatment of benign prostatic hyperplasia.gov/entrez/query. Perrin P. Cheng CW. http://www.6). Mitchell I-DC. Many questions concerning the composition. Raynaud JP.41:497-506. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=12022711& dopt=Abstract 2.1:27.nih.gov/entrez/query. Cochrane Database Syst Rev 2002.ncbi.nlm. Pygeum africanum for benign prostatic hyperplasia. http://www. 5. Phytotherapy in the management of benign prostatic hyperplasia.nlm.ncbi.nlm. A few short term randomized trials and some meta-analyses show clinical efficacy without major side effects for compounds such as Pygeum africanum and Serenoa repens (1-4).gov/entrez/query. Gillenwater JG. Stark G.fcgi?cmd=Retrieve&db=PubMed&list_uids=10510105& dopt=Abstract Chan PSF.3 Surgical management Transurethral resection of the prostate (TURP). Urol Clin North Am 2002. The biological effects in unclear although a few randomized clinical trials show encouraging results. placebo controlled trials are needed (7). J. Two randomized controlled trials (RCTs) are available 38 UPDATE MARCH 2004 . 58(Suppl 1):71-76.3. Daruwala PD. The role of phytotherapy in treating lower urinary tract symptoms and benign prostatic hyperplasia. 12.77:Suppl.nlm.29:23-239. Urology 2001. Fagelman E. Serenoa repens for benign prostatic hyperplasia.ncbi.nlm.2. In some studies the efficacy of these compounds was found to be equivalent to finasteride and α-blockers (5. Koch G. the extraction and the mechanism of action of these compounds still remain unanswered and therefore additional randomized.fcgi?cmd=Retrieve&db=PubMed&list_uids=11869585& dopt=Abstract Wilt T.ncbi.nih.(3):CD001423. Wilt T. Hamdy FC. Stark G. Hargreave TB. Daruwala PD. Can terazosin (alpha blocker) relieve acute urinary retention and obviate the need for an indwelling urethral catheter? Br J Urol 1996.84:622-627. 4. 4. Urol 2000. Wong WS. Ishani A. 13. Rutks I. Ishani A.fcgi?cmd=Retrieve&db=PubMed&list_uids=12109350& dopt=Abstract Lowe FC. Boyle P. Sustained-release alfuzosin and trial without catheter after acure urinary retention: a prospective placebo-controlled. Curr Opin Urol 2002.fcgi?cmd=Retrieve&db=PubMed&list_uids=10796790& dopt=Abstract Fagelman E.fcgi?cmd=Retrieve&db=PubMed&list_uids=12074791& dopt=Abstract Dreikorn K.nih. 4.gov/entrez/query. an electrosurgical modification of the TURP-technique. Hargreave TB. BJU Int 1999.gov/entrez/query. Cochrane Database Syst Rev 2000. Lowe FC. McNeil SA.nih. transurethral incision of the prostate (TUIP) and open prostatectomy are the conventional surgical options.fcgi?cmd=Retrieve&db=PubMed&list_uids=11753128& dopt=Abstract Lowe FC.nlm. Da Silva FC. Mac Donald R.2.nih.
2). particularly for patients with bleeding disorders and small prostates.25% in contemporary series (6. The highest Qmax improvement (+175%) is seen after open prostatectomy (absolute numbers: 8. -60% after TURP.4). Encouraging data are available for all these techniques.16). However. Uroflowmetry The mean increase of Qmax following TURP is 115% (range: 80-150%) (6). TUIP and TUVP have been subjected to a number of RCTs.4 Treatment outcome LUTS All four surgical procedures (TURP. 4. the data of large scale RCT are awaited with interest (12-14).for open prostatectomy. such as a lower incidence of complications.8-10).3. TUIP.6 mL/s) (6. with open prostatectomy leading to slightly superior results (4-11). TUVP is considered an alternative to TUIP and TURP. Coagulating intermittent cutting. Mean improvement of LUTS in a meta-analysis of 29 RCT with a TURP-arm was 71% (range: 66-76%) (6). However. or if resection of bladder diverticula is indicated (8-10).3. Intra. while TURP.2-22. Increased post-void residual volume may also be used as an indication for surgery. The following complications of BPH/BPE are considered strong indications for surgery: • refractory urinary retention • recurrent urinary retention • recurrent haematuria refractory to medical treatment with 5-alpha reductase inhibitors • renal insufficiency • bladder stones. Post-void residual volume All four surgical procedures allow a reduction of the post-void residual volume of more than 50%: -65% after open prostatectomy. Open prostatectomy is the treatment of choice for large glands (> 80-100 mL).7 mL/s (range: 4-11. 4. these methods are not described in more detail below. A recent RCT has shown that Holmium-laser enucleation leads to similar outcome as open prostatectomy for men with large glands (> 100 mL) at a significantly lower complication rate (11). antibiotics are recommended in patients on catheterisation prior to surgery.3. In the 10 RCTs comparing TURP to TUIP. As RCT-data are not yet available. The RCTs comparing TURP to TUVP also revealed similar improvements of LUTS in both study arms (6). The risk of a TUR-syndrome (fluid intoxication. They showed similar improvements of LUTS in patients with small prostates (< 20-30 mL) and no middle lobe (5-7). 4. in absolute terms + 9. TUVP and open prostatectomy) result in an improvement of LUTS exceeding 70%. yet a higher long-term failure rate. serum Na+ < 130 nmol/L) is in the range of 2%. 4. both procedures resulted in a similar improvement in symptoms after 12 months (5-7). The UPDATE MARCH 2004 39 .3. associated complications such as large bladder stones. -60% after TUVP.and postoperative complications are correlated with the size of the prostate and the length of the procedure.2 Choice of surgical treatment Ten RCT comparing TUIP to TURP are available (5-7).5 Complications Intra-/peri-operative Mortality following prostatectomy has decreased significantly within the past two decades and is less than < 0. Variables that most likely predict the outcome of prostatectomy are severity of LUTS. minimal risk of bleeding and blood transfusion. 4. TURP comprises 95% of all surgical procedures and is the treatment of choice for prostates sized 30-80mL. The routine use of prophylactic antibiotics remains controversial. there is a great intra-individual variability and an upper limit requiring intervention has not been requiring intervention has not been defined. and –55% after TUIP (4-11).6 mL/s) (6). TUIP has several advantages has several advantages over TURP.17-19). rotoresection and bipolar electrocautery are electrosurgical modifications of the conventional technique (12-14).1 Indications for surgery The most frequent indication for surgical management is bothersome LUTS refractory to medical management (1. Risk factors for the development of the TUR-syndrome are excessive bleeding with opening of venous sinuses. Following TUVP. the Qmax increased by 155% (range: 128-182%) (6). the degree of bother and the presence of BPO (see above) (3.3 Perioperative antibiotics A known urinary tract infection should be treated before surgery (15. decreased risk of retrograde ejaculation and shorter operating time and hospital stay. prolonged operation time. large glands and past or present smoking (20).3.
8% following TUIP.nih. Sexual function: Retrograde ejaculation results from the destruction of the bladder neck and is reported in 80% after open prostatectomy.nih.ncbi. Barrett L.2-12. The risk of bladder neck contracture is 1. who not want medical treatment but who request active intervention.fcgi?cmd=Retrieve&db=PubMed&list_uids=10492185& dopt=Abstract Pickard R. yet who do not improve after non-surgical (including medical) treatment.81:712-720. Few data are available on the long-term outcome following TUVP. In the 29 RCTs recently reviewed. particularly TURP. 3. such as age. • with a strong indication for surgery.22).19. In addition: • Surgical prostatectomy (open. Immediate and postoperative complications of transurethral prostatectomy in the 1990s.gov/entrez/query.8% after open surgery. REFERENCES Borboroglu PG.157:1304-1308.7 CONCLUSIONS AND RECOMMENDATIONS Surgery should be considered for those men: • who are moderately/severely bothered by LUTS. A secondary prostatic operation is reported at a constant rate of approximately 1-2% per year (4-11). The only RCT that compared TURP to a “wait and see” policy reported identical rates of erectile dysfunction in both arms (4). the incidence of erectile dysfunction following TURP was 6. Kane CJ. 4. http://www. http://www. (18). TURP and TUIP.fcgi?cmd=Retrieve&db=PubMed&list_uids=9120927& dopt=Abstract 2.3. The respective figures for TUVP are in the range of TURP (6). National Prostatectomy Audit Steering Group.nlm. Reda DJ. Phelan M. TURP. J Urol 1999. • with bothersome LUTS.estimated need for blood transfusion following TURP is in the range of 2-5%. TUVP) results in significant subjective and objective improvements superior to medical or minimally invasive treatment.8% after TURP and 1.3. Long-term complications Incontinence: Median probability for developing stress incontinence ranges is 1. Neal DE. on erectile function.8 1. Testing to predict outcome after transurethral resection of the prostate.162:1307-1310.gov/entrez/query. Roberts JL. 40 UPDATE MARCH 2004 . Bladder neck contracture and urethral stricture: The risk of developing an urethral stricture is 2.8-10).gov/entrez/query. The management of men with acute urinary retention. Emberton M. Long-term risk of mortality The possibility of an increased long-term risk of mortality after TURP compared to open surgery has been raised by Roos et al. one RCT reported an incontinence rate of 5% (6. Limited information on this issue is available for TUVP.6 Long-term outcome Retreatment rate Favourable long-term outcome is common after open prostatectomy. The frequently reported rise of erectile dysfunction after TURP is therefore most likely not a direct consequence of TURP but rather caused by confounding factors. Higher percentages have been reported following open prostatectomy (6.ncbi. All four surgical procedures have been evaluated in randomised controlled trials. 65-70% after TURP and 40% after TUIP (4-11). These findings have not been replicated by others (17. Ward JF.7%) (6). and up to 10% following open prostatectomy (4-11). 2. There is a long-standing controversy on the impact of prostatectomy.fcgi?cmd=Retrieve&db=PubMed&list_uids=9634047& dopt=Abstract Bruskewitz RC.ncbi. 4% after TURP and 0.6% after open prostatectomy. 4.3. TUIP.nih.5% (95% Cl: 0.nlm. 3. The risk of bleeding following TUIP and TUVP is negligible (6).21).2% following TURP. J Urol 1997. Wasson JH. Sands JP.4% after TUIP (4-11).7% after TUIP (4-11). • TUIP is the surgical therapy of choice for men with prostates < 30 mL and no middle lobes. Br J Urol 1998.nlm. http://www. 4.
gov/entrez/query. Orestano F. Eur Urol 2001.nlm.nih. 16. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11942959& dopt=Abstract Elmalik EM.ncbi.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=9666765& dopt=Abstract UPDATE MARCH 2004 41 .nlm. Melloni D. http://www. Improved highfrequency surgery in transurethral prostatectomy. Liapi C.ncbi. 10.fcgi?cmd=Retrieve&db=PubMed&list_uids=11857663& dopt=Abstract Tubaro A. 12. http://www. New Engl J Med 1995. Eur Urol 2000. http://www.165:1526-1532.ncbi.nih. A prospective study of the safety and efficacy of suprapubic transvesical prostatectomy in patients with benign prostatic hyperplasia. http://www. Pirritano D. Bruskewitz RC.fcgi?cmd=Retrieve&db=PubMed&list_uids=7527493& dopt=Abstract Yang Q.gov/entrez/query. 13. Eur Urol 1998. J Urol 2002. Trojan L.nih.gov/entrez/query. Hind A.gov/entrez/query. Wasson JH. J Urol 2001.ncbi. Zucchi A. in patients with benign prostatic hypertrophy.ncbi. Wolf D. Fastenmeier K. Kohrmann KU. Leyh H. Peters TJ.gov/entrez/query. The provision of transurethral prostatectomy on a day-case basis using bipolar kinetic technology. Marberger M. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. Pavone-Macaluso M for the members of the Sicilian-Calabrian Society of Urology. Wilt TJ. 5. 9.nlm. Comparison of long-term results of transurethral incision of the prostate with transurethral resection of the prostate.91:65-68.gov/entrez/query.89:534-537. Harmuth H.nih. Urology 2002.fcgi?cmd=Retrieve&db=PubMed&list_uids=12385922& dopt=Abstract Kuntz RM. Neurourol Urody 2002. Alken P.nlm. Fondacaro L.nih.gov/entrez/query.gov/entrez/query. Curto G.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=10233485& dopt=Abstract Tkocz M.fcgi?cmd=Retrieve&db=PubMed&list_uids=11435849& dopt=Abstract Mearini E. Knoll T.168:1465-1469.332:75-79. http://www. 8.nih.nih. http://www. 6.nlm. Vicentini C.ncbi. Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=10705199& dopt=Abstract Scholz M. Abrams P. Single-dose antibiotic prophylaxis in transurethral resection of the prostate: a prospective randomized trial. http://www. Porena M. Donovan JL.37:199-204. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. http://www. http://www. Open prostatectomy in benign prostatic hyperplasia: 10-year experience in Italy. Luftenegger W.nlm.34:480-485. Barba M. Elinson J.gov/entrez/query.nih.ncbi. Transurethral incision compared with transurethral resection of the prostate for bladder outlet obstruction: a systematic review and meta-analysis of randomised controlled trials. Bahar YM.83:227-237.gov/entrez/query.nih.nih. BJU Int 2003.fcgi?cmd=Retrieve&db=PubMed&list_uids=12614253& dopt=Abstract Eaton AC.ncbi.60:623-627. Saad MS.fcgi?cmd=Retrieve&db=PubMed&list_uids=11464057& dopt=Abstract Michel MS. Ibrahim AI. Miano L. LoBianco A. Reda DJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=11342911& dopt=Abstract Madersbacher S.gov/entrez/query. Carter S. Lehrich K.ncbi.4. Is transurethral resection of the prostate still justified? Br J Urol 1999.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=9831789& dopt=Abstract Serretta V.nih. 7. http://www. Rotoresect for bloodless transurethral resection of the prostate: a 4-year follow-up. http://www.nlm. Morgia G.39:676-681.ncbi. Keller AM. J Urol 2001.nlm. Mearini L. Prajsner A. http://www.nlm. 15.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=12352419& dopt=Abstract Hartung R.nlm. 14. Francis RN. Gahli AM. Henderson WG. Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100grm: a randomised prospective trial of 120 patients.nlm. BJU Int 2002. Holtl W.gov/entrez/query.nih. Marzi M. 11.gov/entrez/query. Motta M.nlm. Br J Urol 1998. Risk factors in prostatectomy bleeding: preoperative urinary tract infection is the only reversible factor.166:172-176.21:112-116.81:827-829. Coagulating intermittent cutting.
the results of many studies have been published.ncbi. In subsequent years. Urology 2000. Energy can be delivered through a bare fibre.gov/entrez/query. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia.gov/entrez/query. Breda G. Interstitial treatments depend on inserting the fibre into the prostatic tissue and the use of coagulation techniques (6). 21. Farahmand BY.4. Fisher ES. 18. which cause the tissue to be dehydrated (4. 22. Muto G.ncbi.166:162-165. Operative technique Side-firing laser prostatectomy is performed using Nd:YAG laser light at 1064 nm and relatively high power settings (typically between 40 and 80 W). Mortality and prostate cancer risk in 19.nlm. http://www.gov/entrez/query.8). delivered via an optical fibre equipped with a distal reflecting mechanism. Mandressi A. and other. 4. Andersen TF.5). http://www. resulting in marked improvement in their voiding symptoms. Kessler O. This fibre fits through standard cystoscopes and all laser applications are performed 42 UPDATE MARCH 2004 . KTP:YAG and diode. Holman CD. Smoking increases the risk of large scale fluid absorption during transurethral prostatic resection. Semmens JB. transurethral resection. These.fcgi?cmd=Retrieve&db=PubMed&list_uids=10444122& dopt=Abstract Roos NP. Malenka DJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=10688086& dopt=Abstract Hahn RG.nih. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=2469015& dopt=Abstract Hahn RG. Rouse IL.nlm. when Shanberg et al.fcgi?cmd=Retrieve&db=PubMed&list_uids=11435847& dopt=Abstract Gallucci M. energy levels can be varied to achieve coagulation or vaporization. Resection of a multicentric.598 men after surgery for benign prostatic hyperplasia.nih. http://www. randomised clinical study on 150 patients. Vaporization depends upon temperature changes of over 100oC. Puppo P. reports documented the fact that prostatic tissue ablation could be achieved using the Nd:YAG laser. J Urol 1999.gov/entrez/query.4. Incidence of acute myocardial infarction and cause-specific mortality after transurethral treatments of prostatic hypertrophy. Long-term incidence of acute myocardial infarction after open and transurethral resection of the prostate for benign prostatic hyperplasia. However.nlm. 4. Wisniewski ZS.nih.1 Laser types Four types of laser have been used to treat the prostate: Nd:YAG. Pappagallo GL. There is also secondary tissue slough. (3) reported the use of the Nd:YAG laser to perform prostatectomy in 10 patients with BPH.2).ncbi.nlm. BJU Int 1999. silica-glass. right-angle fibre or interstitial fibre.gov/entrez/query. laser transmission fibre (UrolaseTM fibre) (9). http://www. This effect decreases forward scatter into tissue and may cause less tissue oedema. as far as durability is concerned. McPherson K.55:236-240. Ramsey E. The use of contact lasers using a bare fibre has been abandoned.2 Right-angle fibres From 1991 onward. long-term follow-up results are only available from initial studies. In addition. Perachino M. 19.161:491-493. Shpitz B. reports describing a TRUS-guided. N Engl J Med 1989.84:37-42.nlm.nlm. J Urol 2001. Boccafoschi C. Fredman B.fcgi?cmd=Retrieve&db=PubMed&list_uids=9612677& dopt=Abstract Shalev M. Nissenkorn I.fcgi?cmd=Retrieve&db=PubMed&list_uids=9915433& dopt=Abstract 4.gov/entrez/query. flexible. Richter S. the TULIPTM device was abandoned and other authors experimented with even greater prostatic tissue ablation using a much simpler side-firing Nd:YAG laser delivery system.nih. Comeri G.17.nih. side-firing Nd:YAG laser instrument (the TULIPTM device) for BPH therapy appeared in the urological literature (7.4 Lasers The use of lasers to treat BPH has been contemplated since 1986 but was anecdotal until the early 1990s (1. Bass AJ. Eur Urol 1998. Wennberg JE. Guazzieri S. which is associated with tissue oedema.ncbi.ncbi. Hallin A.33:359-364.ncbi. With the development of the right-angle fibre and the refinement of both equipment and technique. Fortunato P. Cohen MM. This consisted of a gold-plated mirror affixed to the distal end of a standard.320:1120-1124. The difference between coagulation and vaporization is that coagulation causes little vaporization and depends on temperature changes to achieve permanent tissue damage. Holmium:YAG.nih. Hammar N. 20. Francesca F. Persson PG. Transurethral electrovaporization of the prostate vs. http://www.
several studies have demonstrated the ability of side-firing laser prostatectomy to produce a significant improvement in bladder outflow obstruction. Kabalin et al. Post-procedure. sparing its urethral surface. The most commonly used fibres are ITT Light GuideTM. an improvement in voiding occurs only gradually. If randomized studies are considered. ILC can be carried out using the transurethral approach. (18) reported that 85% of men undergoing laser prostatectomy could expect at least a 50% improvement in either prostate symptom score or peak urinary flow rate. Disadvantages are the delayed time to normal voiding and severe dysuria (8. Further long-term follow-up studies are needed. 43. the observed retreatment rates following laser prostatectomy . Retrograde ejaculation has been reported in up to 22% of patients. although they are higher in the TURP arms (12-17). The major limitation of the laser technique compared with conventional TURP is the lack of immediate effect and requirement for urinary catheter drainage for several post-operative days. it is possible to coagulate any amount of tissue at any desired location. with local. As far as complex urodynamic evaluation is concerned. randomized. offer better long-term results and comparable (if not superior) efficacy than laser prostatectomy. No study has reported any occurrence of impotence or sustained incontinence. emergent TURP has been reported to solve this problem (8). the results are quite similar. an Italian retrospective study of 36 patients submitted to side-fire Nd:YAG laser prostatectomy with a minimum follow-up of 5 years reported striking results (23). Catheter irrigation is generally not required and blood loss is statistically lower with Nd:YAG laser coagulation than with TURP because of the excellent haemostasis produced. particularly in patients who are candidates for TURP or TUIP. The UPDATE MARCH 2004 43 . An improvement in voiding produced by side-firing Nd:YAG laser prostatectomy has been extensively documented in the urological literature.seem comparable to documented reoperation rates after TURP (18). During the 3-year post-operative follow-up.1% of TURP patients. or under local peri-prostatic block as described by Leach et al.22). Indigo. Optimal tissue ablation is achieved using long-duration (60-90 seconds) Nd:YAG laser applications to fixed spots along the prostatic urethra.4. these techniques. Conversely. (14) found equivalent voiding outcomes for the two procedures. and most patients do not notice significant benefits until approximately 3-4 weeks post-operatively. favouring laser prostatectomy as a much safer procedure than TURP (12. The objective of ILC of BPH is to achieve marked volume reduction and to decrease urethral obstruction and symptoms. Costello et al. In fact. serious treatment-related complications occurred in 11. Since then. After 5 years. These authors reported that 78.transurethrally under the direct visual control of the surgeon.or 6-months of post-operative follow-up. and the Diffusor-TipTM. Results of pressure-flow studies have been reported by several authors (8. These data therefore suggest caution in giving indications to laser treatment. All patients had undergone pressure-flow studies at 3 months after laser treatment: 32 previously obstructed patients were unobstructed. With regard to durability.6-95% of men undergoing laser treatment were rendered unobstructed at 3.13).8% of these patients underwent TURP because of recurring obstruction. the intraprostatic lesions result in secondary atrophy and regression of the prostate lobes rather than sloughing of necrotic tissue (27). showing an equivalent improvement in symptom scores and increases in uroflow rates in both groups. but again documented differences in morbidity between these operations. men with chronic urinary tract infections and chronic bacterial prostatitis are not good candidates for Nd:YAG laser coagulation of the prostate (18) because of the possibility of infection of the necrotic tissue that remains in situ for several weeks after the operation. Coagulation necrosis is generated within the adenoma. These laser applications are repeated systematically and with considerable overlap until all visible obstructing prostatic tissue has been coagulated (11). prospective evaluation. several variations and technical and procedural developments have been introduced and tested in clinical trials (26). Moreover.approximately 2% per year of followup . The operating time is approximately 45 minutes or less. Operative technique Fibres employed for ILC must emit laser radiation at a relatively low power density. durability and limitations There have been many studies comparing side-fire laser to TURP. As the applicator can be inserted as deeply and as often as necessary. 4. Outcome.3 ILC ILC as a therapy for BPH was first mentioned by Hofstetter in 1991 (25). (10). TURP and TUIP. Even after catheter removal. Nd:YAG lasers or diode lasers are used for ILC.12. Some patients may require catheterization for 3-4 weeks or more (24).8% of laser prostatectomy patients and 35. morbidity. regional or systemic anaesthesia. Both the US and UK multicentre trials documented dramatic differences in serious treatment-related complications. in larger glands significant amounts of obstructive prostatic tissue can be left behind (17). The operation may be performed under general or regional anaesthesia.19-21). Dornier. In a single-institution. Such a retreatment rate is definitely greater than that observed after TURP and even after TUIP. The best results are obtained if the weight of the gland is below 50-60 g.
ILC can be performed in small prostates and also seems to be suitable to debulk larger prostates or to treat highly obstructed patients (26). The results of several studies indicated the effectiveness of ILC in treating BPH with regard to symptoms.4. 25. primarily TURP. 47. but a shorter mean catheter time (20.31.8 minutes.33). rising to 9. which can result in urinary retention and temporary irritative symptoms. durability and limitations Studies were performed to compare the results with ILC with those of other laser techniques. A continuous flow resectoscope is required with a working element.4% with a maximum follow-up of 12 months. with an incidence ranging from 0-11. there were no statistical differences between groups for all the considered parameters.34). only a few studies with a short follow-up have been published to date. p < 0. Within 12 months. and have been reported in approximately 5% of patients. reported on a series of 97 patients with severely symptomatic BPH. there is a temporary increase of obstruction after ILC. (40) presented the results of a prospective. Operative technique Instrumentation for this technique includes a 550-µm end-firing quartz fibre and an 80-W Ho:YAG laser. morbidity. However. Urethral strictures or bladder neck strictures are not common. the longest available follow-up is only 12 months.39). though retrograde ejaculation was occasionally reported. one or two placements are used for each estimated 5-10 cm3 of prostate volume. As for morbidity. and certain disadvantages. 120 patients with urodynamic obstruction have been enrolled with prostates less than 100 g in size (Schafer grade 2). the retreatment rate was 3.35). four ILC patients (8. p < 0. In 394 patients followed for up to 3 years. Muschter et al. Prostatectomy using this energy source is a relatively new technique with the first patient reports appearing in 1995 (37. further comparative randomized studies with longer follow-up are needed to assess the durability of this procedure. residual urine volume and prostate volume (26-31). The retreatment rate is up to 15. although as follow-up becomes longer. such as urgency (25).38). In general. All studies reported marked improvements in symptom score.34. Post-operative catheterization was required for an average of up to 18 days. Post-operative irritative symptoms have been observed in 5-15% of patients (28. urethral opening pressure and urethral resistance. although the catheter was removed within 10 days in more than 70% of cases.0001) and length of hospital stay (26. The basic principle of the technique consists of retrograde enucleation of the prostate and fragmentation of the enucleated tissue to allow its elimination through the operating channel of the resectoscope (38. such as the need for longer post-operative catheterization and the lack of tissue for biopsy. so far.6% thereafter (36).laser fibre is introduced from a cystoscope within the urethra. As a general guideline.2 hours. The Ho:YAG wavelength is strongly absorbed by water and the zone of coagulation necrosis in tissue is limited to 3-4 mm. 48 patients received ILC and 49 underwent TURP (34).4 vs. Comparative studies of Nd:YAG versus prostatectomy have been conducted.0001). solid-state laser that has been used in urology for a variety of endourological applications in soft tissues and for the disintegration of urinary calculi (37). Symptomatic and urodynamic improvement were equivalent in the two groups.4 Holmium laser resection of the prostate (HoLRP) The Holmium laser (2140 nm) is a pulsed.9%.0001) for HoLRP patients. 4. The peak power achieved results in intense tissue vaporization and in precise and efficient cutting ability in the prostatic tissue. which has confirmed the shortterm durability of the procedure (36). normal saline is used as the irrigant. Urodynamic parameters were also measured before and after ILC treatment (32. 37. obstruction and enlargement. No study has reported any occurrence of impotence or sustained incontinence. the results of only one long-term follow-up study are available (36). Preliminary analysis has revealed a longer mean resection time (42.1% per year in the first year. randomized trial comparing TURP with HoLRP. peak flow rate. 44 UPDATE MARCH 2004 .3%) were considered to be treatment failures and underwent TURP. Unfortunately. such as almost no serious morbidity. durability and limitations As this technique is relatively new. the sites for fibre placement are chosen according to where the bulk of hyperplastic tissue is found (26).4 hours.1 vs.0 vs. Outcome. Gilling et al. the retreatment rate is expected to be higher. sufficient to obtain adequate haemostasis (38). Outcome. However. p < 0. morbidity. Currently. Pressure-flow studies demonstrated a sufficient decrease of the intravesical pressure. clearly demonstrating that HoLRP is associated with significantly shorter catheter time and a lower incidence of post-operative dysuria (41). This procedure can be seen as a true alternative to TURP in selected patients with some advantages. The total number of fibre placements is dictated by the total prostate volume and configuration. Prospective and randomized studies were also performed to compare the results achieved with ILC with those of other laser techniques (33) and TURP (30.
gov/entrez/query.147:346A.5 CONCLUSIONS Laser prostatectomy should be advised for patients who are: • receiving anticoagulant medication • unfit for TURP (side-fire or ILC) • wanting to maintain ejaculation (side-fire or ILC) • holmium laser prostatectomy is a viable alternative to TURP and irrespective of any anatomical configuration. The optimisation of laser prostatectomy. Retrograde ejaculation occurs in 75-80% of patients. Laser ablation of the prostate in patients with benign prostatic hypertrophy.43:149-153. Paterson P.nih. Canine transurethral laser-induced prostatectomy. http://www. 6. Br J Urol 1992. the size of the prostate that can be treated depends on the experience and patience of the urologist. J Urol 1992. REFERENCES Kandel LB. Kabalin JN.nih. II. Braslis KG. Baghdassarian R. 10. 4. 9. Urology 1994. UPDATE MARCH 2004 45 . prospective study of endoscopic laser ablation versus transurethral resection of the prostate.nlm. Patients on anticoagulant medication and those with urinary retention can be safely treated (43). the technique is a surgical procedure that requires significant endoscopic skill and cannot be considered easy to learn.46:305-310.46:155-160. A prospective randomized comparison of transurethral resection to visual laser ablation of the prostate for the treatment of benign prostatic hyperplasia.5:145-149. 13.nih. Sirls L.gov/entrez/query. http://www. p.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542818& dopt=Abstract Anson K.gov/entrez/query.4.133:331A.ncbi. Tansey LA. Interstitial laser prostatectomy .6 1. Greskovich FJ.42). Pathologic changes occurring in the prostate following transurethral laser prostatectomy. http://www. 1994.40. Fowler C. Eur Urol 1994.gov/entrez/query.12:254-263. Lasers Surg Med 1992. however. Outpatient visual laser-assisted prostatectomy under local anesthesia. Lasers in Urologic Surgery. Puppo P.fcgi?cmd=Retrieve&db=PubMed&list_uids=7985315& dopt=Abstract Cowles RS 3rd. Bolton DM.Aluminium-Garnet (YAG) laser in the canine model. Cromeens DM. Urology 1994.133:110A. there are no specific limitations to the procedure. Hofstetter A.nlm. 3.nih. 12. Levinson AK. Burt J. A multicenter.fcgi?cmd=Retrieve&db=PubMed&list_uids=7509525& dopt=Abstract Muschter R.fcgi?cmd=Retrieve&db=PubMed&list_uids=1379101& dopt=Abstract Leach GE. Johnson DE. 11. Kirby R. SPIE Proceedings 1991. Ricciotti G. Perachino M. Price RE. Hessel S. USA: Mosby.nlm. Urology 1995.ncbi. The use of the neodymium YAG laser in prostatotomy. McCullough DL. Perlmutter AP. http://www. Transurethral laser prostatectomy: Creation of a technique for using the Neodymium-Yttrium. Roskamp D. Bowsher WG.ncbi.nlm. http://www.44:856–861.gov/entrez/query. Lepor H. randomized. although the presence of a prostate gland over 100 mL is a relative contraindication in urologists' early experience (38). Stein B.Post-operative dysuria is the most common complication. J Endourol 1991.experimental and first clinical results. Woodruff RD et al.fcgi?cmd=Retrieve&db=PubMed&list_uids=7515349& dopt=Abstract Costello AJ. J Urol 1986. Dixon C. no post-operative impotence has been reported (38). Urology 1995. Ganabathi. J Urol 1985. Harrison LH. Childs S. Other lasing techniques. 7.69:603-608.gov/entrez/query. St Louis. Muschter R. 8.ncbi. Laser-tissue interaction. Lawrence W. Stein BS.nih. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=7544932& dopt=Abstract 2. 5. Assimos DG. Shanberg AM. Buckley J. Scannapieco G.ncbi. Johnson DE. Conversely. 4. http://www. In: Smith JA et al. Nawrocki J. Transurethral laser prostatectomy using a right-angle delivery system. eds. Zabbo A. Dmochowski R. Watson G.ncbi. 10.nlm.nlm.25:220-225. McCullough DL. with an incidence of approximately 10% (38.nih.4.1421:36. No major complication has been described. Transurethral ultrasound-guided laser-induced prostatectomy: objective and subjective assessment of its efficacy for treating benign prostatic hyperplasia.
gov/entrez/query. 26.nih. http://www. 27.ncbi. [Prostatectomia laser con metodica side-fire: risultati a distanza di 5 anni. Schettini M.155:310A. Urodynamics and laser prostatectomy. Eur Urol 1999. Neodymium:YAG laser coagulation prostatectomy: 3 years of experience with 227 patients.nlm.nlm. Kahn R et al.155:318A.nih. Plymouth: Health Publications. http://www. 46 UPDATE MARCH 2004 . Debruyne FM. De Wildt MJ. http://www. Rosier PF.nih. Bite G.plymbridge. Whitfield H. Urology 1996. Bruschter R et al.nlm. Lasermedizin 1991.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933807& dopt=Abstract Kabalin JN. 25. 23. http://www. In: Denis L.13:109-114. [Italian] Kabalin JN. http://www. 1998.nlm. Paris. Endourol 1996.11:207-209. Interstitial laser therapy of benign prostatic hyperplasia.gov/entrez/query. Fortunato P et al.nlm.gov/entrez/query. July 1997. Sirls LT.ncbi. Hofstetter A. High-energy visual laser ablation of the prostate in men with urinary retention: pressure flow analysis.gov/entrez/query.12(Suppl 1):44. Kabalin JN.155:181-185. Urology (letter) 1997. Fay R.158:1923. 19.nlm. J Urol 1997. De Wildt M. Whitfield HN. Laser prostatectomy. A randomized prospective multicenter study evaluating the efficacy of interstitial laser coagulation. Asopa R.14.ncbi. pp. Cho G et al. Initial results of a randomized trial comparing interstitial laser coagulation therapy to transurethral resection of the prostate. J Endourol 1997.nih. Doll S. J.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542962& dopt=Abstract Bhatta KM.48:584-588.nlm. 21. Crowe HR. eds.nih. http://www.gov/entrez/query. 18.] Acta Urol Ital 1998.ncbi. J Urol 1996.gov/entrez/query. World J Urol 1995. 22. Jichilinski P et al.ncbi.35:147-154. 529-540.ncbi. Interstitielle Thermokoagulation (ITK) von Prostatatumoren.76:604-610. Khoury S et al.155:316A. Schmidlin F. Urodynamic assessment in the laser treatment of benign prostatic enlargement.gov/entrez/query. Eur Urol 1999. Proceedings of the Fourth International Consultation on BPH.ncbi. J Urol 1996.nih. Puppo P.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542968& dopt=Abstract Choe JM.gov/entrez/query. A new technique of subsurface and interstitial laser therapy using a diode laser (wavelength = 1000 nm) and a catheter delivery device.com/ Perachino M.ncbi. Technique and results of interstitial laser coagulation. 29.fcgi?cmd=Retrieve&db=PubMed&list_uids=9334638& dopt=Abstract Hofstetter A.nih.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933808& dopt=Abstract Muschter R. Oswald M. http://www. Bite G.gov/entrez/query.35:138-146. 24. TURP: modification of laser prostatectomy technique with biodegradable stent insertion. 17. Laser prostatectomy performed with right angle firing neodymium: YAG laser fiber at 40 watt power settings. J Urol 1997. Combination of thermocoagulation and vaporisation using a Nd:YAG/KTP laser versus TURP in BPH treatment: preliminary results of a multicenter prospective randomized study. 15. de la Rosette JJ.13:134-136. J Urol 1996. 31. De la Rosette JJ.ncbi. Neodymium: YAG laser coagulation prostatectomy for patients in urinary retention.fcgi?cmd=Retrieve&db=PubMed&list_uids=9181452& dopt=Abstract Costello AJ.nih. Chan SL. World J Urol 1995.nlm.157(Suppl 1):41. Perlmutter A. Wijkstra H. Br J Urol 1995. J Urol 1996. Results of interstitial laser coagulation of the prostate. Muschter R. 30. Side-firing neodymium:YAG laser prostatectomy. Kabalin JN. Griffiths K. http://www. 28.10 (Suppl 1):S191. Altwein JE. 16.fcgi?cmd=Retrieve&db=PubMed&list_uids=8535680& dopt=Abstract Cannon A. Costello AJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490827& dopt=Abstract Te Slaa E.fcgi?cmd=Retrieve&db=PubMed&list_uids=8886064& dopt=Abstract Stein BS. http://www.7:179-180.nlm. Diana M. Abrams PH. http://www. 20. Long-terms results of randomized laser prostatectomy vs.157:42A.
and transurethral ultrasound-guided laser-induced prostatectomy superior to transurethral prostatectomy? Prostate 1997. Ann Urol (Paris) 1997. Transurethral and transperineal interstitial laser therapy of BPH. http://www.9(Suppl 1):S149.nih. 36. http://www.gov/entrez/query.ncbi. http://www. Denstedt JD. Alken P.nih.ncbi. Holmium: YAG laser resection of the prostate (HoLRP) versus transurethral electrocautery resection of the prostate (TURP): a prospective randomized.nih. 37. Laser prostatectomy with the holmium:YAG laser. Br J Urol 1997.5 Transrectal high-intensity focused ultrasound (HIFU) 4. thus producing a region of high energy density within which tissue can be destroyed without damage to the overlying or intervening structures (1-3). Bartsch G.org/index.gov/entrez/query. 33. Whitfield HN. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=9180936& dopt=Abstract Muschter R. Holmium: YAG laser resection of the prostate (HoLRP) for patients in urinary retention.fcgi?cmd=Retrieve&db=PubMed&list_uids=7633476& dopt=Abstract Chun SS. J Endourol 1997. Cass CB. Greschner M. Combination Holmium and Nd: YAG laser ablation of the prostate: initial clinical experience. Fraundorfer MR. Kabalin JN. J Endourol 1995. Holmium laser resection of the prostate (HoLRP) versus neodymium: YAG visual laser ablation of the prostate (VLAP): a randomized prospective comparison of two techniques for laser prostatectomy.nih.gov/entrez/query. 39. Teillac P.nlm. Bellingham: SPIE Press.80(Suppl 2):A773. controlled.32. 51: 573-577. Kabalin JB. including post-void residual urine volume • Serum PSA • TRUS • Pressure-flow study advisable. http://www. Eur Urol 1999. Desgrandchamps F. Reissigl A. Luppold T.157:149A.nlm. pp. eds.35:155-160.ncbi. the following parameters should be obtained: • I-PSS.nih. The use of an interstitial diode laser (Indigo) in laser prostatectomy. Watson G. 416-423. 42. http://www. 35.ncbi. 40. Malcolm AR. 43.nih. Holmium laser resection of the prostate.nih. In: Muller G et al.ncbi. J Endourol 1995. Anidjar M.ncbi.gov/entrez/query. http://www.nlm. including quality of life • Free uroflowmetry.31:27-37.fcgi?cmd=Retrieve&db=PubMed&list_uids=9376851& dopt=Abstract 4.5. Fraundorfer MR. Muschter R. http://www. de la Rosette JJ.1:217-221. Strasser H. interstitial laser. Gilling PJ. Janetschek G.10(Suppl 1):S197. High power interstitial laser coagulation of benign prostatic hyperplasia.fcgi?cmd=Retrieve&db=PubMed&list_uids=9157819& dopt=Abstract Le Duc A. Fraundorfer MR. Razvi HA. Laser-induced Interstitial Thermotherapy. Cresswell MD. A randomized.31:255-263. J Endourol 1996.5. The Holmium YAG laser in the transurethral resection of prostate.nlm.nlm.gov/entrez/query.ncbi. the predominant UPDATE MARCH 2004 47 . J Urol 1997. urodynamicbased clinical trial. Gilling PJ.cfm?fuseaction=SearchResultsVolume&keywords=Laser-induced%20 Interstitial%20&searchtype=SearchResultsVolume&quicksearch=1&CFID=353971&CFTOKEN=68929120 Horninger W. Thermocoagulation au laser de l’adenome de la prostate par voie interstitielle. Perlmutter AP et al. Malcolm A. Mackey MJ. Sroka R. http://bookstore.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933809& dopt=Abstract Gilling PJ.2 Procedure A beam of ultrasound can be brought to a tight focus at a selected depth within the body.nlm. However. Henkel TO. Kabalin JN. Cresswell M.11:291-293. Fraundorfer MR.fcgi?cmd=Retrieve&db=PubMed&list_uids=9586609& dopt=Abstract Le Duc A. prospective study.gov/entrez/query. 34.gov/entrez/query. Gilling PJ.1 Assessment No specific diagnostic work-up prior to transrectal HIFU therapy is necessary. 38. Hofstetter A. Tech Urol 1995. Urology 1998. Cass CB.nlm.9:151-153. 1995. 41. If the site-intensity is set below the tissue cavitation threshold.fcgi?cmd=Retrieve&db=PubMed&list_uids=9118394& dopt=Abstract Gilling PJ. Are contact laser.spie.
4.200 W/cm2.5-4. Theoretically the prostate can be ablated by HIFU via a transabdominal or transrectal route. This complication led to reconstruction of the filling apparatus and the probe such that the problem can now be reliably avoided. No cases of urethral strictures. The second severe complication was a thermolesion of the rectum requiring surgical intervention. In clinical use. transrectal HIFU should not be considered for severely obstructed patients or those with an absolute indication for surgery. As a consequence. The Qmax increased from 8. In the same time period. The authors concluded that the capability of transrectal HIFU to reduce bladder outlet obstruction was moderate (12).000 W/cm2. although some patients report a decreased ejaculate volume.5. (7) reported on experience with 15 patients and a follow-up of 90 days.4 (± 5.0 cm) is dependent upon the crystal used. The AUA symptom score reduced from 24. Haematospermia for 4-6 weeks is observed in up to 80% of sexually active men.6).4 Outcome In June 1992. Pre-operatively. (13). The site intensity can be varied from 1. After HIFU. In one patient. Similarly.5. 4.5 months following HIFU therapy. an international Phase II clinical trial was initiated to evaluate the safety and efficacy of transrectal HIFU therapy for patients with LUTS due to BPH. several hundred patients have been treated with the Sonablate® at various sites. Thirty patients underwent urodynamic investigations (pressure-flow study) before and after a mean of 4.5) mL/s (12 months. 4. Within the HIFU beam focus.1 (± 6. only transrectal HIFU devices are applied for the indication of BPH. The Qmax increased from 9.6) mL/s (6 months. Clinical data are only available for one device.5. the post-void residual urine volume decreased from 131 (± 120) mL to 48 (± 41) mL at 6 months and to 35 (± 30) mL at 12 months.300 W/cm2. In order to create a clinically useful volume of necrosis.7) at 6 months and to 10.6 mL/s to 15. Within the same time period. n = 33) and 13. Retrograde ejaculation and erectile dysfunction can be safely avoided. The initial report of the study included 50 patients. The histological effect of transrectal HIFU therapy using the Sonablate® on the canine and human prostate has been studied in detail (1-3. The focal length (2.4 (± 4.9 to 7. Haematospermia lasting for a maximum of 4-6 weeks is seen in the majority of sexually active patients. 80% of patients were obstructed and a further 20% were in the intermediate zone according to the Abrams-Griffith nomogram.1. an ellipsoidal tissue volume approximately 2 mm in diameter and 10 mm in length is destroyed (1-3). and patients frequently discharge two to three drops of blood prior to micturition for several weeks. n = 20). This was most likely caused by using an inappropriately high-site intensity exceeding 2. (8) treated 35 patients.1) to 12. Urinary tract infection occurs in around 7% of patients.5. As a consequence. eight of whom had urinary retention. which has the property of changing its thickness in response to an applied voltage (1-3).0 MHz transrectal transducer for imaging and therapy. detrusor pressure at Qmax and linear passive urethral resistance relation was observed. however. yet 37% were still obstructed according to the Abrams-Griffith nomogram. Two severe complications have been reported.7 Durability The long-term outcome of 80 patients with a follow-up of up to 4 years and a minimum follow-up of 2 years 48 UPDATE MARCH 2004 . 20 of whom were followed up for 12 months (5). perforation of the descending colon approximately 50-60 cm above the treatment zone occurred.3 Morbidity/complications In general. transrectal HIFU is well-tolerated but requires general anaesthesia or heavy intravenous sedation. To date.8 (± 2.9 (± 4.7) to 13. incontinence or the need for blood transfusion have been reported in the literature.0 mL/s and the post-void residual urine volume decreased from 154 mL to 123 mL (7).5. who studied in detail the early post-operative morbidity of several less invasive procedures. Ebert et al.therapeutic effect is the induction of heat. The most prominent side-effect is prolonged urinary retention. It was caused by inadvertent overfilling to 500 mL and subsequent rupture of the condom that covered the ultrasound probe. there is little data on sexual function. a statistically significant decrease in maximum detrusor pressure.5 Urodynamics The urodynamic effect of transrectal HIFU therapy has been studied by Madersbacher et al.2 mL/s after 3 months. half of the patients were in the equivocal zone and 13% were clearly unobstructed.3 mL/s to 14. the Sonablate® (1-4). the post-void residual urine volume decreased from 182 mL to 50 mL and the I-PSS from 17. lasting for 3-6 days. (12). The Qmax increased from 7. The source for HIFU is a piezoceramic transducer.5) at 12 months (5).5 (± 4. This system uses the same 4. 4.260 to 2. 4. This technique is known as high-intensity focused ultrasound (HIFU). Bihrle et al.6 Quality of life and sexual function There are no reliable data on quality of life after transrectal HIFU except from a study by Schatzl et al. Several other sites have confirmed these data (9-11).5. a multiplicity of laterally or axially displaced individual lesions is generated by physical movement of the sound-head. In the initial US series. After therapy. the maximum site intensity was set at 2.
http://www.(higher treatment failure rate) • Absolute indication for surgery.isismedical. Fitzpatrick JM.nih.com/ Madersbacher S. Susani M. Tissue ablation in benign prostatic hyperplasia with high intensity focused ultrasound. Effect of high-intensity focused ultrasound on human prostate cancer in vivo. Graefen M. Keio J Med 1995. J Urol 1994. In: Marberger M ed. http://www.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=7512658& dopt=Abstract Ebert T. http://www. Curr Opinion Urol 1998.5. Marberger M. http://www.nlm. Pedevilla M. High intensity focused ultrasound for the treatment of benign prostatic hyperplasia: early United States clinical experience. 4.3 months (range: 13-48 months). UPDATE MARCH 2004 49 . Curr Opinion Urol 1995.ncbi.44:146-149.gov/entrez/query.5. A similar trend. with a treatment failure rate of approximately 10% per year.5.55:3346-3351. Patients with one or more of the following criteria are unsuitable for transrectal HIFU therapy: • Prostates with dense calcifications (possibility of tissue cavitation) • Large prostates (> 75 mL) • Rectum to bladder neck distance over 40 mm • Large middle lobes • Higher grades of bladder outlet obstruction (BOO) .nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7525992& dopt=Abstract Madersbacher S.nlm. Thirty-five men (43. Djavan B. Minimally invasive therapy in BPH.gov/entrez/query.8%) underwent TURP due to an insufficient therapeutic response during the 4-year study period. 2. The mean follow-up of the study population (excluding patients who crossed over to TURP due to insufficient therapeutic response) was 41.nih.03) (14).79:177-180. 5. controlled trials.nih. Marberger M.ncbi.nih. The retreatment-free period was significantly longer for patients with a pre-treatment average flow rate of more than 5 mL/s (p = 0. Vingers L.fcgi?cmd=Retrieve&db=PubMed&list_uids=8587227& dopt=Abstract Mulligan ED. 4.gov/entrez/query.151:1271-1275. 6. High-intensity focused ultrasound for prostatic tissue ablation. Marberger M. 1995. Marberger M. hinders a reliable statement concerning patient selection. Ackermann R.nlm.10 REFERENCES 1. Susani M.ncbi. Improvement of urinary symptoms is in the range 50-60% and Qmax increases by a mean of 40-50%. 8. Long-term efficacy is limited. Mulvin D. was noted for individuals with a higher Qmax and lower post-void residual urine volume. Saddeler D.9 CONCLUSIONS Transrectal HIFU therapy is the only technique that provides non-invasive tissue ablation.152:1956-1960. Marberger M. J Urol 1994.nlm. Lynch TH.05) and lower grades of urodynamically documented bladder outlet obstruction (p = 0. High-intensity focused ultrasound in the treatment of benign prostatic hyperplasia. http://www.5:147-149. pp. 4. Marberger M.fcgi?cmd=Retrieve&db=PubMed&list_uids=9052466& dopt=Abstract 3.8:17-26.nih. Foster RS.gov/entrez/query. Madersbacher S. Oxford: Isis Medical Media. http://www. however. 4. No data are yet available from randomized. Curr Opinion Urol 1996. 9. Applications of high energy focused ultrasound in urology. Madersbacher S. Donohue JP.ncbi. Kratzik C.8 Patient selection The fact that only a handful of clinical studies with a limited number of patients have been published. Madersbacher S. Madersbacher S. Smith JM. High-intensity focused ultrasound (HIFU) in the treatment of benign prostatic hyperplasia (BPH). 7. general anaesthesia or at least heavy intravenous sedation is required. Cancer Res 1995. Miller S. Schmitz-Drager B. which did not reach statistical significance.has been studied (14). Br J Urol 1997. Greene D. Hood JP. Therapeutic applications of ultrasound in urology. yet a few selection criteria have been identified. 115-136.6:28-32. Sanghvi NT. Application of Newer Forms of Therapeutic Energy in Urology.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542168& dopt=Abstract Bihrle R.
6 TUNA® 4.gov/entrez/query. Lang T. A recent report with 5 years follow up in 188 patients demonstrated a symptomatic improvement of 58% and an improvement in flow rate of 41%. Schatzl G. were more frequent in the TURP arm. urinary tract infection or strictures. erectile dysfunction. Continence status is not affected.6.79:172-176.fcgi?cmd=Retrieve&db=PubMed&list_uids=8977064& dopt=Abstract Schatzl G.6% of patients and lasts for a mean of 1-3 days.6. Marberger M. although intravenous sedation is required in some patients (1).3-41. radio-frequency energy to the prostate via needles inserted transurethrally (1). yet a number of patients remained in the obstructed range after TUNA® therapy. 90-95% of patients are catheter-free (1). Baba S.2 Procedure The TUNA® device delivers low-level. although improvements were slightly higher in the TURP arm. Adverse events. Eur Urol 1996.gov/entrez/query. dysuria.ncbi.gov/entrez/query. Saito S. Nakamura K.6 Impact on bladder outflow obstruction The impact of TUNA® on bladder outflow obstruction as assessed by pressure-flow studies was determined in seven clinical studies (7-13).11:197-201.ncbi. Djavan B.30:437-445.ncbi. a statistically significant decrease in maximum detrusor pressure or detrusor pressure at Qmax was demonstrable. McLoughlin MG.158:105-111. Irritative voiding symptoms lasting up to 4-6 weeks are frequently present (2).nih.nlm.nlm. Schatzl G.nlm. J Endourol 1997.nih. within 1 week. Schmidbauer CP.fcgi?cmd=Retrieve&db=PubMed&list_uids=9186334& dopt=Abstract Madersbacher S. The urodynamic impact of transrectal high intensity focused ultrasound on bladder outflow obstruction.6. Klingler CH.10. such as bleeding.nih.1 Assessment No specific diagnostic work-up prior to TUNA® is necessary. 4. Long-term outcome of transrectal high intensity focused ultrasound therapy for benign prostatic hyperplasia.6. http://www. These data are statistically significantly better than at baseline and surpass the expected placebo effect.gov/entrez/query. 21.nih.37:687-694. 12.nlm. there was a significant decrease in AUA symptom score and bother score. Gleave ME. 4.3 Morbidity/complications Is usually performed as an out-patient procedure under local anaesthesia.ncbi. In both treatment arms. The early postoperative morbidity of transurethral resection of the prostate and of four minimally invasive treatment alternatives. Early experience with highintensity focused ultrasound for the treatment of benign prostatic hyperplasia. 14. http://www. Goldenberg LG.4 Outcome Several non-randomized clinical trials have documented the clinical efficacy of this procedure with a fairly consistent outcome (3-7).gov/entrez/query.nlm. Marberger M.fcgi?cmd=Retrieve&db=PubMed&list_uids=10828669& dopt=Abstract 4. The symptomatic improvement reported ranged from 40-70%.6.fcgi?cmd=Retrieve&db=PubMed&list_uids=9181450& dopt=Abstract Sullivan LD.6. 4. 13. Eur Urol 2000. High-intensity focused ultrasound energy for benign prostatic hyperplasia: clinical response at 6 months to treatment using Sonablate 200™. 11. Improvement in Qmax was significantly higher after TURP than after TUNA®. Br J Urol 1997. Marberger M. In all studies. Tachibana M. Marich KW. There is no convincing evidence that prostate size is significantly reduced following TUNA® (7-9). Post-operative urinary retention is seen in 13. http://www. Madersbacher S.ncbi. 50 UPDATE MARCH 2004 . Stulnig T. http://www.5 Randomized clinical trials TUNA® has been compared with TURP in one trial (8) with 12-month follow-up data. Improvements in Qmax vary widely from 26-121% in non-retention patients.2% required additional treatment (8). 4.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9052465& dopt=Abstract Madersbacher S. Murai M. J Urol 1997. 4. http://www.
fcgi?cmd=Retrieve&db=PubMed&list_uids=9186334& dopt=Abstract Ramon J. Wiklund P.nlm. Urol Int 2001. Within 1 year. 4. Issa MM.nih. Garafolo F.gov/entrez/query. Naslund MJ.nlm.gov/entrez/query. http://www. Lang T.ncbi.ncbi.ncbi. 3. UPDATE MARCH 2004 51 . 2003. Ostrem T. Perez-Marrero R.nlm. Roehrborn CG. Maehlum O. Madersbacher S. Cristalli AF.157:98-102. J Urol 1998.44:89-93. (14) recently presented 3-year follow-up data on 49 patients after TUNA®. and there is limited evidence of long-term efficacy.nih.ncbi.6. Chapple CR. Pressure-flow studies in men with benign prostatic hypertrophy before and after treatment with transurethral needle ablation. Br J Urol 1997. 4. Long-term evaluation of transurethral needle ablation of the prostate (TUNA) for treatment of symptomatic benign prostatic hyperplasia: clinical outcome up to five years from three centers. Lynch TH. Perez-Marrero R. Oesterling JE. Br J Urol 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=9240192& dopt=Abstract Roehrborn CG. Naslund MJ.6.nlm. positive results can be translated into percentages ranging from 5-42% (1). Minardi D.fcgi?cmd=Retrieve&db=PubMed&list_uids=9554360& dopt=Abstract Zlotta AR.9 CONCLUSIONS TUNA® is a simple and safe technique and can be performed under local anaesthesia in a significant number of patients. Pillai M.gov/entrez/query. Shumaker BP. Issa MM. http://www. Galosi AB. Shumaker BP.fcgi?cmd=Retrieve&db=PubMed&list_uids=12814680& dopt=Abstract Rosario DJ.nih. Yehia M. multicenter US study.nih. It results in an improvement of urinary symptoms in the range 50-60% and Qmax increases by a mean of 50-70%.gov/entrez/query. Potts KL.8 Patient selection Few selection criteria have been identified.ncbi. Goldwasser B.gov/entrez/query.gov/entrez/query. 8 9. Transurethral needle ablation (TUNA).158:105-110. TUNA® is not suitable for patients with prostate volumes exceeding 75 mL or isolated bladder neck obstruction. http://www.nlm. 4.80:128-134. Frick J. http://www. Issa MM. http://www.ncbi. http://www. Schulman CC.nih.nlm. Schulman et al. Muzzonigro G.gov/entrez/query. Transurethral needle ablation (TUNA) of the prostate: clinical experience with two years’ follow-up in patients with benign prostatic hyperplasia (BPH). Eur Urol. Ekman P. http://www.35:119-128.159:1588-1593. Zlotta AR. Fitzpatrick JM.fcgi?cmd=Retrieve&db=PubMed&list_uids=11223750& dopt=Abstract Bruskewitz R. Urology 1998.66:89-93. 6.51:415-421. The early postoperative morbidity of transurethral resection of the prostate and of four minimally invasive treatment alternatives. Improvement in Qmax exceeding 50% was seen in 53% of patients after 36 months. J Urol 1997.80:579-586. Marberger M. Woo H. Bruskewitz RC.gov/entrez/query. J Urol 1997.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=9352697& dopt=Abstract 2. Woo H. Narayan P.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933805& dopt=Abstract Schatzl G. http://www. Cutinha PE. Giannakopoulos X. Clinical efficacy has been proven in only one randomized controlled trial. Transurethral needle ablation for benign prostatic hyperplasia: 12-month results of a prospective.nih. Transurethral needle ablation of the prostate for the treatment of benign prostatic hyperplasia: a collaborative multicentre study. Giammarco L.nih.nlm. Eur Urol 1999. Ten patients (20%) underwent TURP because of an insufficient therapeutic response (1). Chapple CR. Long-term follow-up data exceeding this time period are not yet available.nlm. Jungwirth A.6. Safety and efficacy of transurethral needle ablation of the prostate for symptomatic outlet obstruction. A critical review of radiofrequency thermal therapy in the management of benign prostatic hyperplasia.4. Eardley I.6.7 Durability Several authors have reported on the long-term efficacy of the TUNA® procedure. 5. A prospective randomized 1-year clinical trial comparing transurethral needle ablation to transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia. 7.ncbi. 4. Hastie KJ. Oesterling JE.fcgi?cmd=Retrieve&db=PubMed&list_uids=9510346& dopt=Abstract Schulman CC.10 REFERENCES 1.
33(Suppl 1):148.gov/entrez/query. http://www. while for high-energy protocols.8).7. 13. To date. the average catheterization time is 2 weeks.ncbi. Sleep DJ.nlm. Transurethral needle ablation (TUNA™) of the prostate: clinical experience with three years follow-up in patients with benign prostatic hyperplasia (BPH). Sweden).fcgi?cmd=Retrieve&db=PubMed&list_uids=9187689& dopt=Abstract Steele GS. On a conceptional basis. although pain medication needs to be administered to most patients prior to or during therapy.7. Fluid channels surrounding the catheter provide urethral cooling. but subsequently higher energy levels were used to improve treatment outcomes and response rates.fcgi?cmd=Retrieve&db=PubMed&list_uids=8683692& dopt=Abstract Millard RJ.gov/entrez/query. Urology 1997. ProstaLund® (Lund Systems. USA).158:1834-1838. Ordesi G. Outcome: objective. 4. Tamaddon K.4 Morbidity Morbidity following TUMT is an important issue. a company considered to be the pioneer of microwave thermotherapy.7.gov/entrez/query. 4. subjective and urodynamics Low-energy protocols: The standard operating software for the Prostatron® is version 2. Also incorporated in the catheter are one or more temperature sensors that differ in the way in which they measure temperature.15:619-628. Issa MM. Corrada P. Only two papers mention erectile dysfunction following thermotherapy (incidence 0. this figure increases up to 44%.7 TUMT 4.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=8916114& dopt=Abstract Campo B. In these cases. Neurourol Urodyn 1996. 11. Other thermotherapy devices have also been developed: Prostcare® (Brucker. a catheter may be necessary for an average of 7 days.nih. J Urol 1996. The main difference between the devices available is the design of the urethral applicator. High-energy treatment is also well-tolerated.nih. 4.156:413-419.10.2). J Urol 1997. urinary retention is usual in patients treated with high-energy TUMT. Eur Urol 1998. they are all similar in delivering microwave energy to the prostate with some type of feedback system.49:847-850.8-5%) (7. Initial experience focused on low-energy protocols. A treatment catheter is connected to the module and inserted into the prostatic urethra. 4. tens of thousands of patients worldwide have been treated with the Prostatron® device.2 Procedure TUMT is a registered trademark of Technomed Medical Systems (France).nih. No tissue sloughing occurs and urinary retention is expected in up to 25% of patients (2-6). Harewood LM. http://www. The majority of data in the literature on thermotherapy has been based on the Prostatron® device.ncbi. Transurethral needle ablation (TUNA) of the prostate: a clinical and urodynamic evaluation.nlm. 12. Zlotta AR. Transurethral needle ablation of the prostate: report of initial United States experience. http://www. the retrograde ejaculation rate ranges from 0-11%. 14. Transurethral needle ablation of the prostate: a urodynamic based study with 2-year follow-up. significantly affecting the heating profile (1.0. Occasionally. and Targis® (Urologix. For patients treated with low-energy protocols. Apart from differences in the construction of the catheter. the characteristics of the applicators differ. Low-energy TUMT is well-tolerated by patients.7. haematuria is noticed. http://www. A study of the efficacy and safety of transurethral needle ablation (TUNA®) treatment for benign prostatic hyperplasia. Most patients experience perineal discomfort and urinary urgency for several days after treatment. In contrast to the low-energy protocol.1 Assessment Diagnostic endoscopy is essential because it is important to identify the presence of an isolated enlarged middle lobe or an insufficient length of the prostatic urethra.nlm.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9334612& dopt=Abstract Schulman CC.nlm. but not usually for longer.nih. France). and remarkably 52 UPDATE MARCH 2004 .3 The microwave thermotherapy principle Microwave thermotherapy devices consist of a treatment module that contains the microwave generator with a temperature measurement system and a cooling system. The similarity in catheter construction consists of the presence of a microwave antenna positioned in the tip of the catheter just below the balloon. Bergamaschi F.ncbi.
High-energy protocol: The first reports on the application of high-energy levels using Prostasoft® 2. Secondly. the mean Madsen score improved from 13.7%) or endoscopic surgery ( 37. a decrease in IPSS from 18. On a conceptual basis. with a decrease in Madsen symptom score from around 13 to 4. the so-called Prostasoft® 3. On the other hand. When applying higher energy levels. the European BPH Study Group performed a multicentre study of 116 patients using high-energy TUMT (20). international.7.5 protocol can therefore be considered to be high-intensity-dose TUMT. SHAM-(placebo) controlled studies (4. It was concluded from clinical experience that a shorter duration of treatment did not alter efficacy or decrease morbidity (22). (29) reported a 5-year retreatment rate in 45 patients of 84.7. with improvements in free flow being 100% and 69%. there was a significant improvement in all clinical parameters. Although the decrease in symptom score was more pronounced after TURP (92%) than after TUMT (78%).9 to 16. In a study by de la Rosette et al. (5.4% with medication (46.9 and an increase in maximum flow rate from 8. a decrease in IPSS from 19. with improvements observed following high-energy TUMT being in the same range as those seen after TURP. These improvements are noted from 6 weeks and persist over a period of 5 years (16. Changes in objective parameters are less pronounced. Recently Tsai et al. There appeared to be a good correlation between the presence of a cavity and uroflowmetry improvement (21). flow rate (34% vs. (24) found in 56 patients. 64%). an increase in maximum flow from 9. In this study.8 mL/s and cavities within the prostatic tissue of 54 of the 56 patients (95%). increase in flow rate (74% vs.1 mL/s to 17. while Daehlin et al. multicentre study against TURP. quality of life (IPSS) (69% vs. Only decrease in prostate volume was higher in the TURP group (51%) than in the PLFT group (30%) (28). Qmax improved from 9. but one patient in each group required another treatment. 4. 94%) or decrease in detrusor pressure at max.5 at 26 weeks.1 to 5. Van Cauwelaert et al. representing a mean improvement of approximately 35% over baseline. 4. at 12 months.7%).1 mL/s at 26 weeks of follow-up. (26) found in 167 patients. Symptomatic improvement is significant.similar clinical results have been reported worldwide from several centres (2-4.5 protocol differed significantly from former protocols. Pace et al. Both groups had showed significant relief of bladder outlet symptoms. Qmax.2 to 7. there was no statistically significant differences between the 2 treatments in decrease in symptom score (66% vs 65%). as measured by pressure-flow studies. These objective and subjective improvements were sustained at 52 weeks. (30) found a retreatment rate after 5 years in 71 patients of 68%. the principle of stepwise energy increments was abandoned and the treatment was initiated at an 80 W energy level. changes to the Prostasoft® software have recently been reported. ProstaLund Feedback Treatment) (27). 4. The best candidates for this treatment protocol appeared to be patients with moderate-to-severe bladder outlet obstruction.7.18) additional TURP was performed in only three out of UPDATE MARCH 2004 53 . Finally. It was concluded that satisfactory results were obtained after both treatments. One-year follow-up results of a prospective randomized study comparing high-energy TUMT with TURP were reported recently (23).4. (3). A randomized study comparing TUMT with TURP was performed by Dahlstrand et al. At 3-months of follow-up TRUS identified a prostatic cavity in almost 40% of patients. the symptomatic improvement was 78% in the TURP group versus 68% in the TUMT group.9-13). (11) reported only low retreatment rates with significant subjective and objective improvements.5. This Prostasoft® 3.15). In a prospective. the cooling temperature starts at a lower value (8oC) and is also linked to rectal temperature. the urethral temperature feedback system was also abandoned. randomized. No serious complications occurred in either group.14.6 at baseline to 5. At 1 year of follow-up. (19) and demonstrated clinically significant improvements. More recently.5 High-intensity-dose protocol Although the results following high-energy TUMT are good. and those with larger prostates (22). Third.7.17).1. the total treatment duration is shortened to only 30 minutes. De La Rosette et al. The clinical efficacy of TUMT has been confirmed in several randomized.6 mL/s at baseline to 14. The mean increase in Qmax is 3-4 mL/s.7 Durability Several studies using low-energy thermotherapy report on surgical retreatment rates for up to 1 year of 11% (25) and 10% (20).5 were published by de la Rosette et al. Firstly. This study showed significant improvement after both TUMT and TURP in symptom score.6 Prostatic temperature feedback treatment A treatment protocol with calculated tissue necrosis based on simultaneous intraprostatic tissue temperature has been introduced with the Prostalund Micowave apparatus (PLFT. at six months. respectively. After TURP and thermotherapy. post-void residual urine volume and grade of bladder outlet obstruction. (18) and Devonec et al. Energy delivery is now guided by the rectal temperature sensor via a feedback loop. the outcome seems improved and may eventually result in a more durable response. 47%).
http://www.nlm.gov/entrez/query. 1992. Scand J Nephrol 1994. http://www. SIU report 3.gov/entrez/query.158:1839-1844. 3. de Wildt MJ. J Endourol 1994.nlm. Sham versus transurethral microwave thermotherapy in patients with symptoms of benign prostatic bladder outflow obstruction.341:14-17. Erlandsson BE. Kiemeney LA. Debruyne FM.28:83-89.fcgi?cmd=Retrieve&db=PubMed&list_uids=8535682& dopt=Abstract Ogden CW.gov/entrez/query.ncbi.78:564-572. Tomera KM. with sustained and durable long-term results.fcgi?cmd=Retrieve&db=PubMed&list_uids=9334613& dopt=Abstract Marteinsson VT.fcgi?cmd=Retrieve&db=PubMed&list_uids=7518982& dopt=Abstract Servadio C.gov/entrez/query. In particular. Transurethral microwave thermotherapy for uncomplicated benign prostatic hyperplasia. with a follow up of 2 years in 155 patients. (31) confirmed these findings.nlm. Bolmsjo M. 6. 4. http://www. Due J. patients in poor health are particularly good candidates for thermotherapy.nih.nih.0): results of a randomized transurethral microwave thermotherapy versus sham study.76:614-618. In: Fitzpatrick JM ed. Non surgical treatment of BPH. Mattiasson A. Froeling FM.ncbi. Reddy P.nih.nih. http://www. The heat is on – but how? A comparison of TUMT devices. J Urol 1997. http://www.gov/entrez/query. 4.10 REFERENCES 1. Debruyne FM. Ramsay JW. Br J Urol 1995. Claro JD.gov/entrez/query. 4.116 patients. Edinburgh: Churchill-Livingstone. Eliasson T.ncbi. J Urol 1993. only 7% failed to respond (33).ncbi. Pettersson S.ncbi. Morbidity after TUMT consists mainly of the need for catheter drainage after treatment due to urinary retention.nih. Cortado PL.nlm. d’Ancona FC.fcgi?cmd=Retrieve&db=PubMed&list_uids=7692092& dopt=Abstract Dahlstrand C.fcgi?cmd=Retrieve&db=PubMed&list_uids=7678047& dopt=Abstract De la Rosette JJM. Lynch JH. Alivizatos G. 7.nlm. with a success rate of 72% after 6 months in 29 patients (32). http://www. 9.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=7524916& dopt=Abstract Francisca EA.8:217–219.gov/entrez/query. In a larger study of 200 patients. 54 UPDATE MARCH 2004 . 5. http://www.7. Hellerstein DK. Johnson H.ncbi.nlm. McKiel CF. 175-186.nih. High-energy TUMT is associated with improved objective results compared with low-energy TUMT. Transurethral microwave thermotherapy versus transurethral resection for symptomatic benign prostatic obstruction: a prospective randomized study with a 2-year follow-up. Regan JB.7.8 Patient selection As the morbidity is relatively low and the treatment can be performed without anaesthesia.9 • • • CONCLUSIONS High-energy TUMT produces significant subjective and objective improvement. Walden M. Quality of life assessment in patients treated with lower energy thermotherapy (Prostasoft 2. Urology 1994. Wagrell L. Transurethral microwave thermotherapy (TUMT) in benign prostatic hyperplasia: placebo versus TUMT. de la Rosette JJ.ncbi. Good results with regard to catheter release have been obtained. Lancet 1993. such patients with retention can benefit from this treatment.nih.150:1591-1596. Hallin A. http://www.gov/entrez/query. 8. Br J Urol 1996. Hendriks JC. Sankey NE. but with increased morbidity. documenting five surgical interventions at 1-year follow-up in 85 patients treated. Transurethral microwave thermotherapy for management of benign prostatic hyperplasia: results of the United States Prostatron Cooperative Study. De Wildt et al.7. Ten years of clinical experience in transurethral hyperthermia to the prostate.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7516577& dopt=Abstract 2.44:58-63. pp.nlm. Carter SS. Rodrigues Netto N.fcgi?cmd=Retrieve&db=PubMed&list_uids=8944513& dopt=Abstract Blute ML. Deirsson G. Ejaculatory dysfunction after transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia.nih. 4.
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8 1. 6. Subsequent review is as for alpha-blocker therapy. provided there is no deterioration of symptoms or development of absolute indications for surgical treatment.3 5-alpha-reductase inhibitors Patients should be reviewed after 12 weeks and at 6 months to determine their response. 5. 5. FOLLOW-UP All patients who receive treatment require follow-up. Patients who subsequently develop chronic retention will require evaluation of their upper tract by serum creatinine measurement and/or renal ultrasound. Long-term follow-up should be scheduled at 3 months to determine the final outcome. RECOMMENDATIONS FOR TREATMENT The WW policy should be recommended to patients with mild symptoms that have minimal or no impact on their quality of life.4 Surgical management Following surgical treatment. Significant post-operative morbidity. Patients who fail treatment should have urodynamic studies with pressure-flow analysis. The following are recommended: • I-PSS • Uro-flowmetry and post-void residual urine volume. but may have a role in the treatment of high-risk patient subgroups.2 Alpha-blocker therapy Patients should be reviewed after the first 6 weeks of therapy in order to determine their response.4. The following are recommended: • I-PSS • Uro-flowmetry and post-void residual urine volume. TUNA® is an encouraging technology as an alternative with acceptable results. alpha-blocker therapy may be continued. Assessment includes: • I-PSS: recommended • Uro-flowmetry and post-void residual urine volume: recommended • Urine culture: optional • Histology: mandatory. UPDATE MARCH 2004 57 . Patients should be reviewed at 6 months and then annually. TUMT is an acceptable alternative to TURP and for those who prefer to avoid surgery or who no longer respond favourably to medication. Alpha-blocker therapy is a treatment option for patients with bothersome LUTS who do not have an absolute indication for surgical treatment. If patients gain symptomatic relief in the absence of troublesome side-effects. The following are recommended: • I-PSS • Uro-flowmetry and post-void residual urine volume. HoLRP is a promising new technique with outcomes in the same range as those of TURP.1 Watchful waiting Patients who elect to pursue a WW policy should be reviewed at 6 months and then annually. 2. 5. 8. Surgical management (TURP. These patients may be candidates for urodynamic assessment and surgical treatment. disappointing long-term data and higher costs have resulted in a substantial decline in the clinical use of lasers. patients may be seen within 6 weeks to discuss the histological findings and to identify early post-operative morbidity. 7. 5. which will depend on the type of treatment modality undertaken. 3. TUIP. It is not recommended as a first-line surgical treatment for patients with LUTS. provided there is no deterioration of symptoms or development of absolute indications for surgical treatment. 4. open prostatectomy) is recommended as first-line treatment for patients with complications due to BPH with (an absolute indication for treatment of) LUTS. 5. 9. Transrectal HIFU therapy is currently not recommended as a therapeutic option for elderly men with LUTS and is considered an investigational therapy. 5 ARI’s are an acceptable treatment option for patients with bothersome LUTS and an enlarged prostate (> 40 mL) and can be used when there is no absolute indication for surgical treatment. 5.
Assessment includes: • I-PSS: recommended • Uroflowmetry and post-void residual urine volume: recommended • Urine culture: optional • Histology where available: mandatory. at 6 months.5 Alternative therapies Long-term follow-up is recommended because of concerns about the efficacy and durability of alternative therapies. The intervals for follow-up will depend on the treatment modality employed.5. and then annually. at 3 months. 58 UPDATE MARCH 2004 . The following time schedule is appropriate for the majority of minimally invasive therapies: within 6 weeks.
Colorectal and Ovarian Cancer Screening Trial predictive positive value Prostate weight.6. Agency for Health Care Policy and Research European multicenter double-blind study to assess the efficacy and safety of Alfuzosin (5 mg twice daily) versus finasteride (5mg once daily) and the combination of both in patients with symptomatic BPH alpha reductase inhibitor American Urological Association Acute urinary retention BPH Impact Index bladder outlet obstruction benign prostatic enlargement benign prostatic hyperplasia blood urea/nitrogen computed tomography Danish Prostate Symptom Score velocity of detrusor contraction at 40 mL volume dihydrotestosterone digital rectal examination European Prostate Cancer Detection Study European Randomized Study of Screening for Prostate Cancer high-energy thermotherapy high-intensity focused ultrasound Holmium laser resection of the prostate International Continence Society International Prostate Symptom Score interstitial laser coagulation intravenous pyelography intravenous urography low-osmolar contrast material Linear Passive Urethral Resistance Relation lower urinary tract symptoms magnetic resonance imaging presumed circle area ratio Proscar Long-term efficacy and safety study Prostate. Quality of life. ABBREVIATIONS USED IN THE TEXT This list is not comprehensive for the most common abbreviations. Symptoms. Lung. Maximum flow rate prostate-specific antigen post-void residual volume average flow maximum flow mean flow for middle 90% of voided volume randomized controlled trial Receiver Operating Characteristics Quality of Life visual laser ablation time from Qmax until 95% of volume voided transrectal ultrasonography transurethral incision of the prostate transurethral microwave therapy transurethral needle ablation transurethral resection of the prostate transurethral electrovaporization Urethral Resistance Index visual laser ablation watchful waiting (deferred treatment) AHCPR ALFIN study ARI AUA AUR BII BOO BPE BPH BUN CT DAN-PSS dL/dt 40 DHT DRE EPCDS ERSPC HE-TUMT HIFU HoLRP ICS I-PSS ILC IVP IVU LOCM LinPURR LUTS MRI PCAR PLESS PLCO PPV PQSF PSA PVR Qav Qmax Qm90 RCT ROC QoL VLAP Tdesc TRUS TUIP TUMT TUNA® TURP TUVP URA VLAP WW UPDATE MARCH 2004 59 .
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